Page 1 of 67

INTRODUCTION
Osteosarcoma is the most common type of bone cancer, and the sixth most common type of
cancer in children. Age at diagnosis is around 15. Boys are more likely to have osteosarcoma than girls,
and most cases of osteosarcoma involve the knee. Although other types of cancer can eventually spread
to parts of the skeleton, osteosarcoma is one of the few that actually begin in bones and sometimes
spread (or metastasize) elsewhere, usually to the lungs or other bones.
The said disease is usually develops from osteoblasts (the cells that make growing bone), it most
commonly affects teens who are experiencing a growth spurt. Most osteosarcomas arise from random
and unpredictable errors in the DNA of growing bone cells during times of intense bone growth. There
currently isn't an effective way to prevent this type of cancer. But with the proper diagnosis and
treatment, most kids with osteosarcoma do recover. (Childhood Cancer: Osteosarcoma. (n.d.). Retrieved
from http://kidshealth.org)

In the United States, the incidence of osteosarcoma is 400 cases per year. The number of cases in
osteosarcoma is slightly higher in males than in females. In males, it is 5.2 per million per year. In
females, the incidence is 4.5 million per year. Osteosarcoma is very rare in young children. However,
the incidence increases steadily with age, increasing more dramatically in adolescence, corresponding
with the adolescent growth spurt. While in the Philippines, each year, about 3,500 new cases of
osteosarcoma have been recorded. (American Cancer Society (2013). Osteosarcoma. Retrieved from
http://cancer.net)
During our duty at Philippine Orthopedic Center, we decided to choose the case of Patient A.D,
14 years old, who was admitted on January 28, 2014 with a chief complaint of mass on the right leg, he
was initially diagnosed with Osteosarcoma Proximal 3rd Tibia Right to consider Primary Malignant
Bone Tumor.
The patients final diagnosis was Osteosarcoma Proximal Tibia status post amputation at the
above right knee and Pulmonary Metastasis. This case study is suitable to the assigned topic given to our
group; Alteration in perception and coordination. As nursing students, we chose this case because we
want to acquire knowledge and understanding of the development and the other complications that may
arise with the disease. Also this case will help us to know the proper nursing interventions and how the
disease will be cured, or to alleviate the symptoms induced by the patients condition. This serves as a
chance for us to provide information and assess him and his significant others to understand the disease
process.


Page 2 of 67

OBJECTIVES
General Objectives:
During the course of the study, the patient and the significant others shall have: acquired
knowledge on the risk factors that have contributed to the development of Osteosarcoma; gain
understanding and demonstrate compliance pertaining to the treatment and management
rendered by the health care team to present reoccurrence of the disease.
Specific Objectives:
The researchers will be able to:
To build a trusting and cooperative relationship with the nurse researchers as well as with the
other members of the health care team.
To gain knowledge on the definition of Ostreosarcoma, its development, risk factors, medical
and nursing management.
The patient will be able to:
To receive the best possible medical and nursing care, leading to a feeling of security, comfort
and good progression of the disease condition.
To demonstrate compliance to the treatment and management.












Page 3 of 67

I. Health History

A. Demographic (Biographic) Data
1. Clients Name or Initial (Optional):Patient AD
2. Gender: Male
3. Age, Birth date: 14 yrs. old/February 22, 1999.
4. Admission: January 28,2014
5. Marital (Civil) Status: Single
6. Race / Nationality: Filipino
7. Religion: Roman Catholic
8. Address:28 Calidania st.Purok 7 ph1 Malanday Marikina City
9. Educational Background :Grade 7
10. Occupation: Student
11. Usual Source of Medical Care: None
Principle diagnosis: Osteosarcoma proximal tibia right and pulmonary metastasis.

B. Source and Reliability of Information
The sources of information are the patients chart, the staff nurses, and the family.

C. Reason(s) for seeking care or chief complaints
As verbalized by the father, his son has a mass on right leg, with a pain scale of 8, the patient
feeling weak and irritable.

D. History of Present Illness/ or Present Health
Patient A.D is a 14 years old male, admitted at the Philippine Orthopedic Center last January 28,
2014 with a chief complaint of right leg mass. 6 months before his confinement his father notices
a small mass at the patients right leg, there was no consultation done to confirm the patients
condition. But since it is progressively growing, the patient underwent consultation to a
specialist. They went to traditional treatment. PTA, the patient consulted in one hospital in
Marikina were in physician seen that his right leg was seriously damage and need to be
amputated, 2 months PTA The patient started experiencing severe pain and become weak,7 days
PTA the patient admitted at the orthopedic ward and all medical management are done.

E. Past Medical History or Past Health
Pediatric/ Childhood/ Adult Illness Cough and cold
Serious/Chronic Illness November 2013 noted a mass on right prox.(r)leg but no consult may
done. The mass seen in leg with tenderness; with the pain scale of 8.the father noted it is a
color brown, it size of 10cm.
Operations-above knee amputated, February 12,2014
Immunization(s)-according to the pt. father his son did not complete his immunization.
Allergies-none
Last examination Date November 2013
Page 4 of 67


Family Genogram
























Father Side Mother Side
Grand mother
Deceased
Unrecalled
Grand father
Deceased
Unrecalled
Brother
Deceased
Unrecalled
Sister
Deceased
CANCER
Grand mother
Deceased
HPN,
unrecalled
Grand father
Deceased
DM
Unrecalled
Eldest sister
Deceased
CANCER
Eldest
brother
58 y/o
Father
55y/o
Brother
Cancer
53y/o
Father
45y/o
Mother
Asthma
57 y/o
Eldest
Brother
54 y/o
Brother
45 y/o
Sister
DM
49 y/o
Eldest
brother
19y/o
Eldest Sister
Asthma
16y/o
Patient ,
Osteosarcoma proximal tibia right
14 y/o

1
st
level

3
rd
level ,
deceased
2
nd
level
1
st
level
1
st
level,
patient
Page 5 of 67

H. DEVELOPMENTAL HISTORY
(Eriksons 8 Stages of Development)
Stage Age Central Task Indicators of
Positive
Resolution
Indicators of
Negative
Resolution


Infancy

birth to 18
months

Trust vs.
Mistrust

learning to
trust others.

Loss of hope.
He achieved to
trust because
he expressed
his feelings.
Early
Childhood
18 months to
3 years
Autonomy vs.
Shame and doubt

Ability to
express his
feelings.
Lack of
confidence in
their own
powers
throughout
life.
He knows
what will
happen to him,
but he still
hoping for
positive
outcome.
Late
Childhood
3-5 years Initiative vs.
guilt

ability to
evaluate ones
own
behaviour.

Lack of self-
confidence
and he
became
habitual
negative
response to
certain
behaviors.

He develops
awareness of
his guilt, guilt
triggers, and
how to
effectively
assess and
cope with
feelings.
School Age 6-12 years Industry vs.
Inferiority
Beginning to
create,
develop and
manipulate;
developing
sense of
competence
and
perseverance

Loss of hope,
to his
condition,
Withdrawal
from school
and peers.

He develops
inferiority to
his self.
Adolescence 12-20 years Identity vs. role
confusion

Sense of self
plans to
actualize
ones abilities.
Ability to
have possible
anti-social
behaviour
He come to be
anti-social
because in his
condition. .

According to Erikson, The developmental task for adolescent (12-20) identity vs. role confusion.
Erikson claimed that in this stage the child will develop a sense of basic trust in the world and in his
ability to affect events around him. According to the patient when the time he knows his condition he
loses his faith and He afraid for what happen to his self also he said that he is worthless.
Page 6 of 67

Because for what he known about his amputated, the patient started develop a sense of mistrust and
will not have confident into his self.
I. Review of System
System Normal Findings Abnormalities
General Vital Signs:
Blood pressure: 90/60
mm/Hg to 120/80 mm/Hg
Breathing: 12 - 20 breaths
per minute
Pulse: 60 - 100 beats per
minute
Temperature: 36.5-37.5 C
Normal weight: 105 - 125 lbs

Mood/affect:

Color: evenly colored without
lesions or discoloration



100/60mmHg



20cpm



75bpm



37.0c


77lbs


Blunted

Pale


(+) weight loss
Integument
Skin







Hair

>Inspection reveals evenly
colored skin tones without
unusual or prominent
discoloration.

>skin is smooth and even.


>skin pinches easily and

>Pallor (loss of color)



>clammy and smooth in
texture


>Hair is black in color and
Page 7 of 67

Nails immediately return to its original
position


>scalp is clean and dry





>nails are clean



evenly distributed.
Oily in appearance and elastic
in texture


>nail beds were pale in color.
It is clean and was cut short.
Has a capillary refill of 1-
2seconds
Head Symmetric and round


No lesions and mass palpated
>Asymmetric due to presence
of a tender tumor on the
posterior parietal part of the
head with approximately a
size of a normal tomato.

>(+) throbbing-like headache
with a pain scale of 6 over 10
Eyes Eye movement should be smooth
and symmetric throughout all six
directions.
>(-) eyeglasses

>Pale conjunctiva

>Teary eyes

>Pupils are reactive to light

Mouth and Throat Lips are smooth and moist
without lesions or swelling.
>Dry

>Pale in color

>(-) lesions
Respiratory Breath sounds from anterior and
posterior chest exhibit normal

Characteristics. There is no
presence of adventitious sounds.
>(+) crackles sound upon
auscultation


Page 8 of 67

Neck Symmetric with head centered
and no bulging masses enlarge or
tender lymph No manifestation of
goiter. No evidence of lumps and
swollen glands was been
palpated. The neck can move
smoothly, freely and can be
controlled without any indication
of limit in motion.
>symmetric with the head
centered

>(-) bulging masses or
enlarge tender lymph nodes

>neck can move freely
Mouth and Throat Lips are smooth and moist
without lesions or swelling.
Pallor or dry lips
Respiratory Respiration of 16-20cpm.
Characteristics: There is no
presence of adventitious sounds.
The scapulae are both symmetric
and the shoulders are at equal in
horizontal position.

>20bpm

>(+) crackles hear upon
auscultation.

>symmetric scapulae

>equal in horizontal position.
Cardiovascular Pulse rate of 80-100bpm
indicates normal findings.

No presence of murmurs.
No indication of dyspnea
>pulse rate: 75bpm

>Blood pressure:
100/60mmHG

>(-) murmurs

>(-) dyspnea
Gastrointestinal Stool - Solid, Light Brown

>(+) weight loss from 77lbs to
70lbs

> (+) BM once and the stool
is formed and brown in color.

>poor appetite
>flat abdomen
Musculoskeletal Stand on heels and toes along
with evenly distributed weight.
Toes are pointed forward in
straight position and lie flat.
>Right knee amputated with
panthom limb pain

>patient has been
Page 9 of 67

Together with feet it is aligned
with the lower leg. The skin is
smooth and free from calluses.
Knees are symmetric with
hollows present on both sides of
the patella. Posture is erect with
coordinated movements and arms
swings opposition. Mouth opens
and closes smoothly with no
visible swelling and redness on
the area. Spine is straight,
cervical and lumbar spines are
concave while thoracic spine is
convex. Both shoulders are
symmetrically round with no
evidence of redness, swelling and
deformities. The clavicle and
scapulae are also even and
symmetric.
experiencing muscle
weakness

>appears restless

>experiencing fatigue

>(+) generalized body
weakness

>immobilized to ROM

>can flex his left leg but in
slow manner and with help of
relatives.
Neurologic Toes usually point forward and
lie flat; however, they may point
in or point out. Toes and feet are
in alignment with the lower leg,
smooth, rounded medial
malleolar prominences with
prominent heels and
metatarsophalangeal joints. Skin
is smooth and free of corns and
calluses. Longitudinal arch; most
of weights bearing is on foot
midline
>(+) headache with a pain
scale of 6 over 10 as
moderate.

>(+)throbbing pain in the
head

>(-)visual problem

>(+)tumor on the posterior
parietal part of the head.


Endocrine No enlargement of veins is
visible in the head.
CNS is functioning well.
>(-)diabetes or history of
diabetes

>(-) enlarged lymphnodes





Page 10 of 67

2. Laboratory Studies / Diagnostics
BLOOD CHEMISTRY
Examinations
Normal
Findings / Values

Actual Finding

Significance /
Interpretation
Explanations of the
Findings
(as too High or Low)
Hgb

Indication
The oxygen-carrying
pigment of red blood
cells that gives them their
red color and serves to
convey oxygen to the
tissue
180 - 160 (g/L)
12/26/13
143

1/15/14
130

1/28/14
130

2/5/14
113

2/7/14
118
Low hemoglobin was
anemia, or the person
was described as being
anemic.
Hct

Indication
A measure of the packed
cell volume of red cells,
express as a percentage
of the total blood volume.
0.37 0.57%
12/26/13
0.44


1/15/14
0.38


1/28/14
0.39


2/5/14
0.34


2/7/14
0.34


Within normal range.


Within normal range.



Within normal range.



A low hematocrit was
referred to as being
anemic.

A low hematocrit was
referred to as being
anemic.

Page 11 of 67

WBC

Indication
This is used to determine
if there is infection
present.
4.8-10.8 x 10^9/L
12/26/13
9.0

1/15/14
9.8


1/28/14
11.07






2/5/14
11.98



2/7/14
10.58



Within normal range.


Within normal range.



High white blood cells
means there was some
kind of infection or
inflammation in the
body.

High white blood cells
means there was some
kind of infection or
inflammation in the
body.

High white blood cells
means there was some
kind of infection or
inflammation in the
body.
Protrombin Time

Indication
Test measures how
quickly your blood clots.
11-15 seconds
2/5/14
15.7

2/7/14
15.1


Slightly elevated means
there was vitamin K
deficiency from
malnutrition.
Prothrombin
Time International
Normalized Ratio (INR)

Indication
Test measures how
quickly your blood clots.
0.08-1.1 seconds
2/5/14
1.20

2/7/14
1.14
Slightly elevated means
there was vitamin K
deficiency from
malnutrition.
Page 12 of 67





Erythrocyte
Sedimentation Rate
ESR (Westergren)

Indication
A blood test that can
reveal inflammatory
activity in your body.
Less than 15
1/28/14
25

2/5/14
66
High means that there
was Inflammation
present.
DATE EXAMINATION INDICATION IMPRESSION
December 27, 2013
RIGHT KNEE/LEG
X-RAY
A bone x-ray is used to
look for injuries or
conditions affecting the
bone.
Primary Bone Tumor
With Aggresive
Maliognant Features
Consider Osteosarcoma,
Right Tibia
CLINICAL CHEMISTRY
December 26, 2013
Examinations
Normal
Findings / Values
Actual Finding
Significance / Interpretation
Explanations of the Findings
(as too High or Low)
Alkaline
Phosphatase
(ALP)
Indication
Check bone
problems
as rickets, bone
tumors, Paget's
disease, or too
much of the
hormone that
controls bone
growth
(parathyroid
74.0-390.0 U/L
4712.2
Very high enzyme levels are present
in patients with osteogenic bone
cancer or osteosarcoma.
Page 13 of 67




hormone).

BLOOD CHEMISTRY

Examination
Normal
Findings / Values
Actual Finding

Significance /
Interpretation
Explanations of the
Findings
(as too High or Low)
Potassium

Indication
Involved in the function of
nerves, control of muscles, the
maintenance of normal blood
pressure, and has a protective
effect against hypertension.
3.5 - 5.3 mmol/L
1/28/14
4.83

2/3/14
4.87

2/8/14
4.47
Within normal
range.
Sodium

Indication
An important electrolyte that
helps maintain the balance of
fluid in a person's body; helps
to regulate the amount of
water in and around your
body's cells.
135 - 148 mmol/L
1/28/14
135.00

2/3/14
135.40

2/8/14
131

Within normal
range.

Within normal
range.

Low sodium
indicates
dehydration.
Chloride

Indication
A major extracellular anion;
it is not actively regulated
normally. It reflects changes
in sodium
98 - 107 mmol/L
1/28/14
92.70

2/3/14
98.90

2/8/14
97.30
Low cause by
dehydration.

Within normal
range.

Low cause by
dehydration.


Page 14 of 67

































DATE EXAMINATION INDICATION
PATHOLOGIC
DIAGNOSIS
December 15, 2013

PROXIMAL
TIBIA, RIGHT,
TROCAR
BIOPSY



The process
that entails
performing the
imaging studies
required to
determine the
characteristics and
local extent of the
tumor and the
presence of
metastatic disease.
Osteoblastic
Osteosarcoma
DATE EXAMINATION INDICATION IMPRESSION
February 4, 2014
Computed
Tomography Scan
of Chest
Noninvasive
diagnostic imaging
procedure that uses
a combination of X-
rays and computer
technology to
produce horizontal,
or axial, images
(often called slices)
of the body.CT
scans are more
detailed than
standard X-rays.
Multiple varisized
Pulmonary nodules,
consider metastatic
lung disease from a
Probable Aggressive
bone Tumor of the
proximal Tibia.
Page 15 of 67

SOCIO-ECONOMIC
According to the father he earned approximately 1000 pesos weekly from his work(Sapatero) while his
wife earned 400 pesos /day by washing clothes of their neighbours.

J. FUNCTIONAL ASSESSMENT
HEALTH PERCEPTION
According to the patients father his son experienced pain in the right part of his knee in the past. The
doctor told them, the cause of his disease is because of his sports basketball, his son loves eating junk
food and he doesnt want to eat vegetables and meat during their mealtime.
SELF-ESTEEM, SELF CONCEPT /SELF PERCEPTION PATTERN
According to the patient father, his son love to play basketball outside their house with his friends,
however when the illness started he became weak and feeling tired also his son is not afraid to show
himself and ready to fight as long as he is in right side. When he got amputated he said that he is
worthless and he wants to die as verbalized by the patient.
ACTIVITY/EXERCISE PATTERN
According to the patient father, his son does simple household chores before going to the basketball
court to play with his friends. His son is not in the playing area he is in front of television to watch his
favorite cartoons.
NUTRIONAL STATUS
According to the patients father, his son is not eating vegetables and meat during their meal time but
loves to eat junk food and drink soft drinks, but when the illness started his son loss his appetite. He
also not already takes his breakfast and he is seen some changes to his physical appearance. They buy
their water in a delivery water truck. That they use for their cooking, washing clothes and so on.

K. PERSONAL/SOCIAL HISTORY
According to the patient father ,his son is a happy person and not shy to socialite with others ,his son
loves to play basketball rather than staying on their house .Before going outside to play basketball his
son finished his homework first .He is the third child among 3 siblings.

L. ENVIRONMENTAL HISTORY
According to the father they lived in Marikina city in a squatter area. Their house is made of wood and
some portion is made up cement with two rooms. Since their house is near in squatter area there are
still trees around them that serve as their resting area and they have vegetable garden
Page 16 of 67


II. PATHOPHYSIOLOGY CLIENT BASE
























Diagnostics
Factor
Process and Cause
Predisposing Factor:
14 years old
Male
Family History of Cancer
Teenage growth spurt
Precipitating Factor:
Strenuous Activity
Deactivation of tumor
suppressor gene
Mutation of the
Osteoblast

Activation of Oncogenes
Proliferation of malignant
Osteoblast
Uncontrolled growth of tumor
in the bone
Suspension of
red bone marrow
Increase pressure
inside
Pain and
Swelling
Irregular
production of
blood
Osteosarcoma
Cancer cells
metastasize
Decrease RBC
Hemoglobin:
118g/L
Hematocrit:
0.34

Increase
WBC
Leukocytes:
11.98^g/L

Infection
Anorexia
Pallor
Anemia
Fatigue
Body Weakness
Dizziness
Above Right
Knee
Amputation
Blood
Transfussion
Increase
ALP: 4712.2
U/L
Tumor at
parietal part
of the head
Sign and Symptoms
Outcome/Dx
Other complication
Treatment/Management
Legend:
Page 17 of 67


Pathophysiology:

The etiology in mutation in DNA is unknown, predisposing factors include young age (14 yrs.
old), male, family history and teenage growth spurt while precipitating factors include: strenuous
activity. Once there is mutation in DNA the proto oncogenes becomes oncogene and the tumor
suppressor gene will deactivate or it will lose its function. Proto oncogenes is a good cell that provide
signals that lead to cell division and tumor suppressor gene works as guardian of cells. When the
oncogene is activated and the tumor suppressor gene lose its function or deactivate, the cell will became
malignant until it will create a daughter cell that is a malignant osteoblast. Then the malignant osteoblast
will proliferate until there will be uncontrolled growth of tumor.
The existence of uncontrolled growth of tumor will cause increase in pressure inside that will
result to pain and swelling. It will also lead to suppression of bone marrow that causes irregular
production of blood like low hematocrit and low hemoglobin and increased in wbc that results to
infection. A decrease in hematocrit and hemaglobin will result to fatigue, anorexia, pallor, dizziness,
general body weakness, anemia. Increased in atp is also a result if metastasized uncontrolled growth of
tumor. The medical1 treatment for this is above knee amputation.
Page 18 of 67


Page 19 of 67


III. Concept Mapping

Key Demographic Data:
Clients Initial: A.D.
Age: 14 years old
Gender: Male

Reason/s for Needing Health Care:
Palpable mass on the right leg

Medical Diagnosis:
Osteosarcoma Proximal Tibia s/p amputation at the above right
knee and Pulmonary Metastasis

Key Assessments:
BP: 100/60 mmHg
RR: 20 cpm
PR: 75 bpm
TEMP: 37.0
o
C

Pain scale of 6 as moderate
Crying
Facial grimace
Dizziness
Guarding behavior
Loss of appetite
AKA, Right
Limited ROM
Difficulty turning
General body weakness
Reluctance to change position
Nonassertive behavior
Avoidant behavior
Increased alertness
1. Acute Pain, moderate,
throbbing headache related
to decreased oxygen supply
to the head as evidenced by
verbalization of feelings.
3. Impaired skin integrity
related to AKA secondary
to Osteosarcoma as
manifested by reluctance to
change position.
7. Grieving related to
anticipated loss of
physiologic well-being as
evidenced by verbalization
of feelings.
5. Impaired physical mobility
related to insufficient
muscle strength as
manifested by body
weakness secondary to
Osteosarcoma.
2. Electrolyte imbalance
related to sensible fluid loss
as manifested by vomiting.
6. Anxiety related to threat of
death as evidenced by
feelings of helplessness.
4. Imbalanced Nutrition: Less
than Body Requirements
related to decreased food
intake secondary to
Osteosarcoma as evidenced
by loss of appetite.
9. Risk for infection related to
tissue destruction secondary
to Osteosarcoma evidenced
by AKA, Right.
8. Situational low self-esteem
related to doubt regarding
acceptance by others as
evidenced by negative
feelings about his body.
Weak looking
Weight loss, from
77lbs to 70lbs
BMI of 13.7
(underweight)
Leg circumference :
15 cm
Forearm
circumference: 16 cm
Hgb: 118
Na: 131mmol/L
Cl: 92.70mmol/L
Leukocytes: 9.8/L

Page 20 of 67

IV. Problem List

A. ACTUAL or Active
Problem No. Problem Remarks
1
Acute Pain, moderate, throbbing headache
related to decreased oxygen supply to the head
as evidenced by verbalization of feelings.
Resolved. After 4 hours of
nursing interventions the
patient verbalized decreased of
pain from 6 as moderate to 4
using the pain scale of 0-3 as
mild, 4-6 as moderate and 7-10
as severe.
2
Electrolyte imbalance related to sensible fluid
loss as manifested by vomiting.
Resolved. After 8 hours of
nursing interventions the
patient remained free of
complications from electrolyte
imbalance such as decrease
consciousness.
3
Impaired skin integrity related to AKA
secondary to Osteosarcoma as manifested by
reluctance to change position.
Resolved. After 2 days of
nursing interventions, the
patients skin remained intact
and free from rashes, bruising
or tears.
4
Imbalanced Nutrition: Less than Body
Requirements related to decreased food intake
secondary to Osteosarcoma as evidenced by loss
of appetite.

Resolved. After 4 hours of
nursing interventions the
patient verbalized
understanding of individual
interferences to adequate
intake.
5
Impaired physical mobility related to
insufficient muscle strength as manifested by
body weakness secondary to Osteosarcoma
Resolved. After 2 days of
nursing interventions, the
patient remained free from
complications of immobility
such as respiratory problems,
contractures, and decubitus.
6
Anxiety related to threat of death as evidenced
by feelings of helplessness.
Resolved. After 4 hours of
nursing interventions the
patient displayed appropriate
range of feelings and lessened
fear.
7
Grieving related to anticipated loss of
physiologic well-being as evidenced by
verbalization of feelings.
Resolved. After 4 hours of
nursing interventions the
patient expressed feeling of
grief freely and effectively.
8
Situational low self-esteem related to doubt
regarding acceptance by others as evidenced by
negative feelings about his body.
Resolved. After 4 hours of
nursing interventions the
patient verbalized
understanding of body
changes, acceptance of self in
situation.
Page 21 of 67


A. HIGH RISK or Potential
Problem No. Problem Remarks
1
Risk for infection related to tissue destruction
secondary to Osteosarcoma evidenced by AKA,
Right

Resolved. After 8 hours of
nursing interventions, the
patient remained free from
signs of infection,
inflammation, purulent
drainage, erythema and fever




Page 22 of 67



Acute Pain

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation
Subjective:
Masakit po ang
ulo ko as
verbalized by the
patient.

Objective:

Pain scale of
6 as moderate.


Crying
Facial
grimace
Dizziness
Guarding
behavior
Hgb of 118

Acute Pain,
moderate,
throbbing
headache related
to decreased
oxygen supply to
the head as
evidenced by
verbalization of
feelings.
After 4 hours of
nursing
interventions the
patient will
verbalize decrease
of pain from 6 as
moderate to 4
using the pain
scale of 0-3 as
mild, 4-6 as
moderate and 7-
10 as severe.
Independent:
Determined pain
history such as
intensity using
rate of pain scale
of 0-10, location
of pain, frequency
and duration.
Provided no
pharmacological
comfort measures
such as massage
as well as
diversional
activities such as
reading.
Encouraged use
of stress
management
skills and
complementary
therapies such as
relaxation
techniques.

Dependent:
Administered
Celecoxib 1tab BID
as ordered by the

Information
provides baseline
data to evaluate
need for and
effectiveness of
interventions.

Promotes
relaxation and
helps refocus
attention.




Enables client to
participate
actively in
nondrug treatment
of pain and
enhances sense of
control.



A wide range of
analgesics and
associated agents
After 4 hours of
nursing
interventions the
patient verbalized
decreased of pain
from 6 as
moderate to 4
using the pain
scale of 0-3 as
mild, 4-6 as
moderate and 7-
10 as severe.
Goal met
Page 23 of 67

physician. may be employed
around the clock
to manage pain.






Page 24 of 67


Fluid and electrolyte imbalance

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation
Subjective:

Sinusuka niya
lang ang kinakain
niya. as
verbalized by the
patients father.

Objective:

Inadequate
drinking of
water
Loss of
appetite
VS taken:
BP: 100/80
mmHg
PR: 75 bpm
RR:20 cpm
T: 37

Laboratories
Date:
Feb.8/14
Na:
131mmol/L
Cl:
92.70mmol/L


Electrolyte
imbalance related
to sensible fluid
loss as manifested
by vomiting.
After 8 hours of
nursing
interventions the
patient will be
free of
complications
resulting from
electrolyte
imbalance such as
decrease
consciousness.
Independent:
Monitored heart
rate and rhythm
by palpitation and
auscultation.










Auscultated
breath sounds,
assess rate and
depth of
respirations and
ease of respiratory
effort, observe
color of nail beds,
as indicated.
Reviewed clients
food intake. Note
presence of
anorexia,
vomiting, and
unusual diet; look
for chronic

Tachycardia,
bradycardia and
other
dysrhythmias are
associated with
potassium,
calcium and
magnesium
imbalances.
Weak pulse and
thready pulse can
be associated
with
hypokalemia.
Certain
electrolyte
imbalances such
as hypokalemia,
can cause or
exacerbate
respiratory
insufficiency.

Many factors,
such as inability
to drink, large
diuresis or
chronic kidney
failure, trauma or
surgery affect

After 8 hours of
nursing
interventions the
patient remained
free of
complications
from electrolyte
imbalance such as
decrease
consciousness
Goal Met.
Page 25 of 67

malnutrition.






Evaluated motor
strength and
function, noting
steadiness of gait,
handgrip strength
and reactivity of
refluxes.
Reviewed
laboratory results
for abnormal
findings.








Monitored for
nausea and
vomiting,
weakness,
vasodilation.
Dependent:
Administered
metoclopramide
as ordered by the
physician.
individuals fluid
balance,
disrupting
electrolyte
transport,
function, and
excretion.
Which can
provide clues for
electrolyte
imbalance.



Electrolytes
include sodium,
potassium,
calcium, chloride,
bicarbonate and
magnesium.
These chemicals
are essential in
many bodily
functions
including fluid
balance.
Which suggests
mild to moderate
elevation of
magnesium level.
(>3.5-5.0 mEq/L)
To reduce
potential of
complications
associated with
medication-
Page 26 of 67



induced
electrolyte
imbalances.

Page 27 of 67

Impaired Skin Integrity
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:
Hindi ko na maigalaw
yung paa ko , as
verbalized by the
patient
Objective:
(+) AKA, Right
unwillingness to
change position
Crying
Facial grimace
Pain scale of 6/10
as moderate pain
PR: 89bpm
RR: 20cpm
BP: 100/80 mmHg
Impaired skin
integrity related to
AKA secondary to
Osteosarcoma as
manifested by
reluctance to change
position.


After 2 days of
nursing interventions,
the patients skin will
remain intact and free
from rashes, bruising
or tears
Independent:
- Assessed skin
surfaces and pressure
points routinely,
noting moisture, color
and elasticity.

- Observed for
reddened or blanched
areas or skin rashes.

- Handled client
gently

- Maintained skin
hygiene, using mild
soap and drying
gently and thoroughly

- Monitored vital
signs and recorded




- Early detection of
bed sores provides
early intervention



- Reduces likelihood
of progression to skin
breakdown.

- To prevent bruising
and injury

- To prevent drying of
the skin



- To obtain baseline
data and note for any
deviation; suggestive
of presence of
infection

- Promotes
normalization of
After 2 days of
nursing interventions,
the patients skin
remained intact and
free from rashes,
bruising or tears.
Goal Met
Page 28 of 67


- Encouraged light
activities such as
sitting, changing
positions and deep
breathing



- Emphasized the
importance of
adequate nutritional
and fluid intake

organ function;
promotes good
circulation and faster
recovery; for
prevention of
respiratory infections

- To maintain general
good health and skin
turgor.

Page 29 of 67


Imbalanced Nutrition: Less than Body Requirements

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation
Subjective:
Pumayat na siya
kumpara nung bago siya
maipasok sa ospital as
verbalized by the
patients father.

Objective:

Loss of appetite
Generalized body
weakness
Dizziness
Hgb of 118
Weight loss, from
77lbs to 70lbs
BMI of 13.7
(underweight)
Anthropometric
measurement:
Leg
circumference
: 15 cm
Forearm
circumference:
16 cm
Imbalanced
Nutrition: Less
than Body
Requirements
related
decreased food
intake
secondary to
Osteosarcoma
as evidenced by
loss of appetite.

After 4 hours of
nursing
interventions the
patient will
verbalize
understanding of
individual
interferences to
adequate intake.
Independent:
Measured skin
fold thickness.
(other
anthropometric
measurement)





Assessed skin and
mucous
membranes for
pallor, delayed
wound healing
and inflamed
parotid glands.

Encouraged the
client to eat high-
calorie, nutrient
rich diet with
adequate fluid
intake.


If these
measurements
fall below
standards,
clients chief
source of
stored energy,
fate tissue, is
depleted

Helps in
identification
of protein-
calorie
malnutrition.



Supplements
can play an
important role
in maintain
adequate
protein and
caloric intake.
After 4 hours of
nursing
interventions the
patient verbalized
understanding of
individual
interferences to
adequate intake.
Goal Met
Page 30 of 67









Encouraged
verbalization of
perception about
nutrition intake.



Provided health
teaching about
adequate food
intake.


Dependent:

Administered
Metoclopramide
100mg/tab TID as
ordered by the
physician.



Often a source
of emotional
distress,
especially SO
who wants to
feed client
frequently.
Interfere with
stimulation of
true vomiting
center.


Page 31 of 67

Impaired Physical Mobility
Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective:
no verbal cues


Objective:

AKA, Right
Limited ROM
Difficulty
turning
General body
weakness
Dizziness
Reluctance to
change position
Weak looking

Impaired physical
mobility related to
insufficient muscle
strength as
manifested by body
weakness secondary
to osteosarcoma

After 2 days of
nursing
interventions, the
patient will remain
free from
complications of
immobility such as
respiratory
problems,
contractures, and
decubitus.
Independent:
- Noted factor/and
current situation that
contributes to
immobility
(amputation);
Determined
functional level
classification: Level
2 (requires help
from another person
for assistance)

- Noted emotional
responses to
problems of
immobility


- Observed for
presence of
complications
related to
immobility such as
pneumonia,
decubitus and
contractures.

- To determine
intervention to be
given to patient









- Feelings of
frustration or
powerlessness may
impede attainment
of goals

- Early detection
would provide early
intervention





After 2 days of
nursing
interventions, the
patient remained
free from
complications of
immobility such as
respiratory
problems,
contractures, and
decubitus.
Goal Met
Page 32 of 67


-Provided skin care
as appropriate

- Provided
diversional activities
as appropriate


-Encouraged patient
and S/O to continue
passive exercise.


-Encouraged patient
to take adequate
amount of fluids and
nutritious foods.

- Encouraged patient
to verbalize
concerns and
discomfort

- Provided patient
safety, side rails up.

- Kept patient rested.


- To maintain safe
skin.

- To divert patients
attention from
current situation;
promotes relaxation

- To maintain and
enhance gains in
strength and muscle
control.

- Promotes
wellbeing and
maximizes energy
production.

- To promote open
communication; To
be able to address
needs appropriately.

- To prevent patient
injury.

- Promotes rest and
enhance coping
abilities
Page 33 of 67



Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation
Subjective:
Natatakot po
ako, hindi ko
alam kung may
magagawa pa ako
sa mundong ito,
mamamatay na
ako as
verbalized by the
patient.

Objective:

Crying
Shows
avoidant
behavior
Increased
alertness
Anxiety related
to threat of death
as evidenced by
feelings of
helplessness
After 4 hours of
nursing
interventions the
patient will
display
appropriate range
of feelings and
lessened fear.
Independent:
Encourage the
client to share
thoughts and
feelings.



Maintain frequent
contact with
client. Talk with
and touch client,
as appropriate.





Permit
expressions of
anger, fear and
despair without
confrontation.
Give information
that feelings are
normal and are to
be appropriately
expressed.

Provides
opportunity to
examine realistic
fears and
misconceptions
about diagnosis.

Provides
assurance that the
client is not alone
or rejected,
conveys respect
for and
acceptance of the
person, fostering
trust.

Acceptance of
feelings allows
client to begin to
deal with
situation.





After 4 hours of
nursing
interventions the
patient displayed
appropriate range
of feelings and
lessened fear.
Goal Met.
Page 34 of 67











Note ineffective
coping such as
poor social
interactions,
helplessness,
giving up
everyday
functions, and
usual sources of
gratification.


Encourage and
foster client
interaction with
support systems,
including
counselors,
spiritual leader,
and local cancer
resources.






Identifies
individual
problems and
provides support
for client and
significant others
in using effective
coping skills.




Reduces feelings
of isolation. If
family support
systems are not
available, outside
sources may be
needed
immediately.
Page 35 of 67


Anxiety

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation
Subjective:
Natatakot po
ako, hindi ko
alam kung may
magagawa pa ako
sa mundong ito,
mamamatay na
ako as
verbalized by the
patient.

Objective:

Crying
Shows
avoidant
behavior
Increased
alertness
Anxiety related
to threat of death
as evidenced by
feelings of
helplessness
After 4 hours of
nursing
interventions the
patient will
display
appropriate range
of feelings and
lessened fear.
Independent:
Encourage the
client to share
thoughts and
feelings.



Maintain frequent
contact with
client. Talk with
and touch client,
as appropriate.





Permit
expressions of
anger, fear and
despair without
confrontation.
Give information
that feelings are
normal and are to
be appropriately
expressed.

Provides
opportunity to
examine realistic
fears and
misconceptions
about diagnosis.

Provides
assurance that the
client is not alone
or rejected,
conveys respect
for and
acceptance of the
person, fostering
trust.

Acceptance of
feelings allows
client to begin to
deal with
situation.





After 4 hours of
nursing
interventions the
patient displayed
appropriate range
of feelings and
lessened fear.
Goal Met.
Page 36 of 67








Note ineffective
coping such as
poor social
interactions,
helplessness,
giving up
everyday
functions, and
usual sources of
gratification.


Encourage and
foster client
interaction with
support systems,
including
counselors,
spiritual leader,
and local cancer
resources.






Identifies
individual
problems and
provides support
for client and
significant others
in using effective
coping skills.




Reduces feelings
of isolation. If
family support
systems are not
available, outside
sources may be
needed
immediately.
Page 37 of 67


Grieving

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation
Subjective:

Ang dami ng
tumutubong bukol
sa katawan ko,
malapit na akong
mamatay. As
verbalized by the
patient.

Objective:

Crying
Irritable
Angry
Grieving related
to anticipated loss
of physiologic
well-being as
evidenced by
verbalization of
feelings.
After 4 hours of
nursing
interventions the
patient will
express feeling of
grief freely and
effectively.
Independent:
Assessed client
and significant
others for stage of
grief currently
being
experienced.







Provided open,
nonjudgmental
environment. Use
therapeutic
communication
skills.

Encouraged
verbalization of
thoughts and
concerns,
accepting
expressions of
sadness, anger
and rejection.


Knowledge about
the grieving
process
reinforces the
normalcy of
feeling and
reactions being
experienced,
helping client to
deal more
effectively with
them.

Promotes and
encourages
realistic dialogue
about feelings
and concerns.


Client may feel
supported in
expression of
feelings by the
understanding
that deep and
often conflicting
emotions are
normal.

After 4 hours of
nursing
interventions the
patient expressed
feeling of grief
freely and
effectively.
Goal Met
Page 38 of 67






Be aware of mood
swings, evidence
of conflict,
expressions of
anger and
hostility and other
acting our
behavior.



Note signs of
debilitating
depression. Listen
to statements of
guilt, despair and
hopelessness.

Identified positive
aspects of the
situation.





Encouraged
patient to divert
his attention.





May be clients
way of
expressing
feelings of
despair and
spiritual distress
reflecting
ineffective
coping and need
of interventions.

Study shows that
cancer patients
are at higher risk
for suicide.



Possibility of
remission and
slow progression
of disease and/or
new therapies can
offer hope for the
future.

Promotes refocus
of attention.
Page 39 of 67


Page 40 of 67

Situational low self-esteem

Assessment

Diagnosis

Planning

Interventions

Rationale

Evaluation
Subjective:

wala na akong
silbi sa
buhay,hindi ko na
magagawa ang
ginagawa ko dati
As verbalized by
the patient.

Objective:

Crying
Irritable
Angry
Nonassertive
behavior
Situational low
self-esteem
related to doubt
regarding
acceptance by
others as
evidenced by
negative feelings
about his body
After 4 hours of
nursing
interventions the
patient will
verbalize
understanding of
body changes,
acceptance of self
in situation.
Independent:
Determine clients
awareness of own
responsibility for
dealing with
situation, personal
growth and so
forth.

Verify clients
concept of self in
relation to
cultural/ religious
ideals.


Note nonverbal
body language.





Active-listen
clients concerns
and negative
verbalizations
without comment
or judgment.

Help client

When a client is
aware of and
accepts own
responsibility,
may indicate
internal locus of
control.

May provide
client with
support or
reinforce
negative self
evaluation.

Incongruencies
between verbal
and nonverbal
communication
require
clarification.

To allow clients
verbalization of
feelings.




When able to

After 4 hours of
nursing
interventions the
patient verbalized
understanding of
body changes,
acceptance of self
in situation.
Goal met
Page 41 of 67

identify own
responsibility and
control in
situation.



Assist client to
problem -solve
situation,
developing plan
of action and
setting goals to
achieve desired
outcomes.

Encourage use of
visualization,
guided imagery
and relaxation.

Support
independence in
ADLs or mastery
of therapeutic
regimen .

Involve extended
family or
significant others
in treatment plan.
acknowledge
what is not ofhis
control, client can
focus attention on
area of own
responsibility.

Enhances
commitment to
plan, optimizing
outcomes.





To promote
positive sense of
self.


Confident
individual is
more secure and
positive in self-
appraisal.

Increases
likelihood they
will provide
appropriate
support to client.
Page 42 of 67


Risk for Infection
Assessment Diagnosis Planning Intervention Rationale
Page 43 of 67


Subjective:
no verbal cues


Objective:

(+) AKA, Right
LEUCOCYTES =
9.8/L
TEMP = 37.0
Risk for Infection related to
destruction of tissue as
evidenced by AKA, right
leg secondary to
osteosarcoma.

After 8 hours of nursing
interventions, the patient
will remain free from signs
of infection, inflammation,
purulent drainage,
erythema and fever
Independent:
- Practiced and stressed
proper hand washing




- Observed for localized
signs of infections at
surgical site/wound

- Monitored vital signs and
recorded




- Encouraged light
activities such as sitting,
changing positions and
deep breathing






- Encouraged to eat food
rich in vitamin C


- Reduces the risk of spread
of microorganisms; prevent
contamination of the area.


- Provides early detection
of developing infectious
process.

- To obtain baseline data
and note for any deviation;
suggestive of presence of
infection

- Promotes normalization
of organ function; promotes
good circulation and faster
recovery; for prevention of
respiratory infections





- To boost immune system

- Premature discontinuation
of treatment may result in
return of infection and
potentiation of drug
resistant strains.
Page 44 of 67






- Emphasized necessity of
taking antibiotics as
indicated.



Dependent:

- Administer Cefuroxime
as indicated

- Prepare for and assist for
wound dressing if
indicated.




- Taken as prophylaxis to
prevent infection.

- May be necessary to keep
wound dry and clean to
prevent development of
infection.
Page 45 of 67

V. Medical and Surgical Management
Procedure Indication Nursing Responsibilities
Blood Transfusion

Red blood cell transfusions are
used to treat hemorrhage and
to improve oxygen delivery to
tissues. Transfusion of red
blood cells should be based on
the patient's clinical condition.
Indications for transfusion
include symptomatic anemia
Pre:
Verify the physicians
written order and make a
treatment card according
to hospital policy.
Observe the 10 Rs when
preparing and
administering any blood or
blood components.
Explain the
procedure/rationale for
giving blood transfusion to
reassure patient and
significant others and
secure consent. Get patient
histories regarding
previous transfusion.
Explain the importance of
the benefits on Voluntary
Blood Donation Request
prescribed blood/blood
components from blood
bank to include blood
typing and cross matching
and blood result of
transmissible Disease.
Using a clean lined tray,
get compatible blood from
hospital blood bank.
Wrap blood bag with clean
towel and keep it at room
temperature.
Have a doctor and a nurse
assess patients condition.
Countercheck the
compatible blood to be
transfused against the
crossmatching sheet
noting the ABO grouping
and RH, serial number of
each blood unit, and
Page 46 of 67

expiry date with the blood
bag label and other
laboratory blood exams as
required before
transfusion.
Get the baseline vital signs
BP, RR, and Temperature
before transfusion. Refer
to MD accordingly.
Give pre-meds 30 minutes
before transfusion as
prescribed.
Intra:
Check the doctors order
Secure patients consent.
Check the blood typing
and crossmatching.
Observe the 10 Rs.
Do hand hygiene before
and after the procedure.
Prepare equipment
needed for BT (IV
injection tray, compatible
BT set, IV catheter/
needle G 19/19, plaster,
torniquet, blood, blood
components to be
transfused, Plain NSS
500cc, IV set, needle
gauge 18 (only if
needed), IV hook, gloves,
sterile 22 gauze or
transplant dressing, etc.
If main IVf is with
dextrose 5% initiate an IV
line with appropriate IV
catheter with Plain NSS
on another site, anchor
catheter properly and
regulate IV drops.
Open compatible blood
set aseptically and close
the roller clamp. Spike
Page 47 of 67

blood bag carefully; fill
the drip chamber at least
half full; prime tubing
and remove air bubbles
(if any). Use needle g.18
or 19 for side drip (for
adults) or g.22 for pedia
(if blood is given to the
Y-injection port, the
gauge of the needle is
disregarded).
Disinfect the Y-injection
port of IV tubing (Plain
NSS) and insert the
needle, from BT
administration ser and
secure with adhesive tape.
Close the roller clamp of
IV fluid of Plain NSS and
regulate to KVO while
transfusion is going on.
Transfuse the blood via
the injection port and
regulate at 10-15gtts/min
initially for the first 15
minutes of transfusion
and refer immediately to
the MD for any adverse
reaction.
Observe/Assess patient
on an on-going basis for
any untoward signs and
symptoms such as flushed
skin, chills, elevated
temperature, itchiness,
urticaria, and dyspnea. If
any of these symptoms
occur, stop the
transfusion, open the IV
line with Plain NSS and
regulate accordingly, and
report to the doctor
immediately.
Swirl the bag gently from
time to time to mix the
Page 48 of 67

solid with the plasma N.B
one B.T set should be
used for 1-2 units of
blood.
When blood is consumed,
close the roller clamp, of
BT, and disconnect from
IV lines then regulate the
IVF of plain NSS as
prescribed.
Post:
Continue to observe and
monitor patient post
transfusion, for delayed
reaction could still occur.
Re-check Hgb and Hct,
bleeding time, serial
platelet count within
specified hours as
prescribed and/or per
institutions policy.
Discard blood bag and
BT set and sharps
according to Health Care
Waste Management
(DOH/DENR).
Fill-out adverse reaction
sheet as per institutional
policy.


Procedure Indication Nursing Responsibilities
Above Knee Amputation

Tumors of the lower extremity
with major nerve involvement,
as with tumors in proximal
tibia.

Pre:
Check the doctors order.
Secure patients consent.
Check the 10 Rs.
If time permits, review the
physicians explanation of
the scheduled amputation.
Remember that the patient
faces not only the loss of a
body part, with an attendant
change in body image, but
Page 49 of 67

also the threat of loss of
mobility and independence.
Keep in mind too that loss
of a limb or a digit can be
emotionally devastating to
the patient; be sure to
provide emotional support.
If possible, arrange for the
patient to meet with a well-
adjusted amputee who can
provide additional
assurance and
encouragement.
Discuss post-operative care
and rehabilitation measures.
Demonstrate appropriate
exercises to strengthen the
remaining portion of the
limb and to maintain
mobility; such exercises
may include active hip
extension and abduction
and adduction for the above
knee amputation.
Follow the physicians or
physical therapists
directions in explaining
such exercises.
The patient may be fitted
with prosthesis while
hospitalized, but most often
he will equire more time to
heal and so will be
discharged before being
fitted.
Explain to him that the
duration between
amputation and fitting of
the prosthesis varies,
depending on wound
healing, muscle tone and
overall stump condition.
Point out the possibility of
phantom limb sensation.
Explain that the patient
may feel{ sensation of
Page 50 of 67

pain, itching, or numbness
in the area of amputation,
even though the limb or
digit has been removed.
Reassure him that these
sensations.
Administer broad-spectrum
antibiotics as ordered, to
minimize the risk of
infection.
Post:
After the patient returns
from the surgery, monitor
his vital signs frequently as
per facility protocol.
Be alert, particularly for
bleeding through the
dressing. Notify the
physician if bleeding
occurs.
If ordered, elevate the limb
on a pillow or other support
for 24 to 48 hours; be
aware, however that this
could lead to contractures.
Check the dressings
frequently and change them
as necessary.
Assess drain patency and
note the amount and
character of drainage.
Assess the pain and provide
analgesics and other pain
control measures as needed,
because movement may be
painful and interfere with
therapy.
Distinguish distal limb pain
from phantom sensation;
severe, unremitting stump
pain may indicate infection
or other complications.
Keep the stumped properly
wrapped with elastic
compression bandages. A
proper applied bandage is
Page 51 of 67

essential to stump care; it
supports soft tissue,
controls edema and pain
and shrinks molds and limb
into a cone-shaped form to
allow a good fit for the
prosthesis.
Rewrap the limb atleast
twice per day to maintain
tightness.
Emphasize the proper body
alignment and regular
physical therapy to
condition the limb and
prevent contractures and
deformity.
Encourage him to turn from
side to side and to assume
an alternative position-
usually prone position-
from time to time
throughout the day.
Frequent position changes
will stretch the hip flexor
muscle and prevent
contractures.
If the patient has had a leg
amputation, instruct him
not to prop the limb on
pillow to avoid hip flexion
contracture.




Procedures Indication Nursing Responsibilities
Thoracic Biopsy

A biopsy is necessary before
determining the final level of
amputation. In general,
transmedullary amputation is
now performed for bony
sarcomas of the distal femur,
although historically a hip
disarticulation was
Pre:
Check the Doctors order.
Check the patients
consent.
Instruct the patient about
the procedure.
Page 52 of 67

recommended. A failed limb-
sparing procedure of the distal
femur can still be treated with
a high AKA.

Patient Preparation:
Giving the patient and
significant others complete
learning and teaching
guidelines regarding the
surgery.
Providing an opportunity
for the patient to describe
his reactions and feelings in
the stressful situation.
Advise the patient to have
deep breathing exercise.
Do not take any
nonsteroidal anti-
inflammatory medication
(i.e. Motrin, Ibuprofen, and
Aleve) or Aspirin products
for 1 week prior to your
surgery date.
Intra:
Instruct the patient to
remove any jewelry or
other objects that may
interfere with the
procedure.
The patient instructed to
remove clothing and will be
given a gown to wear.
Post:
Instruct the patient to have
deep breathing.
Clean the wound and
change the dressing on your
incision site.



Page 53 of 67



Page 54 of 67

Page 55 of 67


Drug Name Doze Indications

Actions Side Effects Adverse
Reactions
Nursing
Responsibilities

Generic name:

Tramadol
HCL


Brand name:

Ultra


Classification:

Analgesic


25mg
IV Q8
x 3
days


Managemen
t of
moderate to
moderately
severe pain.
Centrally
acting
opiate
receptor
agonist
that
inhibits
the
uptake of
norepinep
hrine and
serotonin,
suggestin
g both
opioid
and
nonopioi
d
mechanis
ms of
pain
relief.
May
produce
opioid-
like
effects,
but
causes
less
respirator
y
depressio
n than
morphine
.

Dizziness,
sedation,
drowsiness,
impaired
visual
acuity
CNS: Drowsin
ess, dizziness,
vertigo,
fatigue,
headache,
somnolence,
restlessness,
euphoria,
confusion,
anxiety,
coordination
disturbance,
sleep
disturbances,
seizures.
CV: Palpitatio
ns,
vasodilation.
GI: Nausea,
constipation,
vomiting,
xerostomia,
dyspepsia,
diarrhea,
abdominal
pain, anorexia,
flatulence.
Body as a
Whole: Sweati
ng,
anaphylactic
reaction (even
with first dose),
withdrawal
syndrome
(anxiety,
sweating,
nausea,
tremors,
diarrhea,
piloerection,
panic attacks,
paresthesia,
hallucinations)
with abrupt
discontinuation
.
Skin: Rashes
Assess for level of pain
relief and administer
prn dose as needed but
not to exceed the
recommended total
daily dose.
Monitor vital signs and
assess for orthostatic
hypotension or signs of
CNS depression.
Discontinue drug and
notify physician if S&S
of hypersensitivity
occur.
Assess bowel and
bladder function; report
urinary frequency or
retention.
Use seizure precautions
for patients who have a
history of seizures or
who are concurrently
using drugs that lower
the seizure threshold.
Monitor ambulation and
take appropriate safety
precautions.
Control environment
(temperature, lighting)
if sweating or CNS
effects occur.
WARNING: Limit use
in patients with past or
present history of
addiction to or
dependence on opioids.

Page 56 of 67
















Drug Name Doze Indications

Actions Side Effects Adverse
Reactions
Nursing
Responsibilities

Generic name:

Paracetamol


Brand name:

tylenol,
biogesic


Classification:

Analgesic or
anti-pyretic
agent

5mg
1tab/da
y
PO
This
medication
is a non-
opiate,
analgesic
and
antipyretic,
prescribed
for
headache,
pain (muscle
ache,
backache)
and fever
either alone
or combined
with other
medications.
It changes
the way the
body senses
pain and
cools the
body

oral
calcium-
channel
blocker
of the
dihydrop
yridine
class.
Nausea,
stomach
upset, skin
rash, acute
toxicity may
result in
liver failure.

Stimulation,
drowsiness,
nausea,
vomiting,
abdominal
pain,
hepatotoxicity,
hepatic
seizure(overdos
e, Renal
failure(high,
prolonged
doses),
leucopenia,
neutropenia,
hemolytic
anemia (long
term use)
thrombocytope
nia,
pancytopenia,
rash, urticaria,
hypersensitivit
y, cyanosis,
anemia,
jaundice, CNS,
stimulation,
delirium
followed by
vascular
collaps,
convulsions,
coma, death.
Assess patients fever
or pain: typeof pain,
location, intensity,
duration, temperature,
and diaphoresis.

Assess allergic
reactions: rash,
urticaria; if these occur,
drug may have to be
discontinued.

Teach patient to
recognize signs of
chronic overdose:
bleeding, bruising,
malaise, fever, sore
throat.

Tell patient to notify
prescriber for pain/
fever lasting for more
than 3 days.
Page 57 of 67























Drug Name Doze Indication
s

Actions Side
Effects
Adverse
Reactions
Nursing
Responsibilities

Generic
name:
Co-
amoxiclav


Brand name:
Augmentin,
Clavamox

Classificatio
n:
Antibiotic


625mg/tab
TID x 1
week
post-
surgical
infections
Inhibits
enzymes
involved
information
of
peptidoglyca
n layer of
bacterial cell
wall No
effect on
human cell
wallsBacteri
cidal; only
works
ondividing
bacteriaWell
absorbed
enterallyCla
vulanic acid
inhibits
bacterial-
lactamase
Diarrhea,
vomiting,
anaemia
rashes
Allergic
reactions,
itching,
rashes, fever.
cross-allergy
with other
penicillins,
diarrhea.
Ask patients history
of allergy
Assess bowel pattern
before and during
treatment as
pseudomembranous
colitis may occur.
Report haematuria or
oliguria as high doses
can be nephrotoxic.
Assess respiratory
status.
Observe for
anaphylaxis.
ensure that the patient
has adequate fluid
intake during diarrhea
attack.
patient must ensure
that they take the full
course od the medicine.
the medicine must be
taken in equal doses
around the clock to
maintain level in the
blood.
Page 58 of 67






Drug Name Doze Indications

Actions Side Effects Adverse
Reactions
Nursing
Responsibilities

Generic name:
Ranitidine


Brand name:
Zantac


Classification:
Histamine
(H2)
antagonist


150mg/
tab
TID x
3days


Short-term
treatment of
active
duodenal
ulcer
Short-term
treatment of
active,
benign
gastric ulcer

Ranitidine
blocks
histamine
H2-
receptors in
the stomach
and
prevents
histamine-
mediated
gastric acid
secretion. It
does not
affect
pepsin
secretion,
pentagastri
n-
stimulated
factor
secretion or
serum
gastrin.
Headache,
dizziness
Rarely
hepatitis,
thrombocyto
paenia,
leucopaenia,
hypersensitiv
ity,
confusion,
gynecomasti
a, impotence,
somnolence,
vertigo,
hallucination
s.
Potentially
Fatal: Anaph
ylaxis,
hypersensitiv
ity reactions.

Administer oral drug
with meals and at
bedtime.
Decrease doses in renal
and liver failure.
Provide concurrent
antacid therapy to
relieve pain.
Administer IM dose
undiluted, deep into
large muscle group.
Arrange for regular
follow-up, including
blood tests, to evaluate
effects.

Page 59 of 67





Drug Name Doze Indications

Actions Side Effects Adverse
Reactions
Nursing
Responsibilities

Generic name:
Cefuroxime

Brand name:
Pharex


Classification:
Anti-
infetives


750mg
IV Q8

Moderate to
severe
infections
including
those of
skin, urinary
infections.
Interferes
with
bacterial
cell wall
synthesis
and
division
by
binding
to cell
wall,
causing
cell to
die.
Active
against
gram-
negative
and
gram-
positive
bacteria,
with
expanded
activity
against
gram
negative
bacteria.
Diarrhea
Nausea
Vomiting
GI
Discomfort
Headache
Hypersensit
ivity
Reaction

No Reported
Side Effect

Monitor neurologic
status, particularly for
dins of impending
seizures.
Advice patient to
immediately report rash
or bleeding tendency.
Instruct patient to take
drug with food every 12
hours as prescribed.
Page 60 of 67


Drug Name Doze Indications

Actions Side Effects Adverse
Reactions
Nursing
Responsibilities

Generic name:
Celecoxib


Brand name:
Celebrex


Classification:
Analgesic


1 tab
BID


Used for the
relief of
pain, fever,
swelling,
and
tenderness
caused
by osteoarth
ritis, juvenil
e
arthritis, rhe
umatoid
arthritis,
and ankylosi
ng
spondylitis.
Celecoxib
blocks the
enzyme
that makes
prostagland
ins
(cyclooxyg
enase 2),
resulting in
lower
concentrati
ons of
prostagland
ins. As a
consequenc
e,
inflammati
on and its
accompany
ing pain,
fever,
swelling
and
tenderness
are
reduced.
Celecoxib
differs from
other
NSAIDs in
that it
causes less
inflammati
on and
ulceration
of the
stomach
and
intestine (at
least with
short-term
use) and
does not
interfere
with the
clotting of
blood
upset
stomach,
diarrhea,
bloating,
gas;
dizziness,
nervousness
, headache;
runny or
stuffy nose,
sore throat;

chest pain,
weakness,
shortness of
breath,
slurred
speech,
problems
with vision
or balance;
black,
bloody, or
tarry stools;
coughing up
blood or
vomit that
looks like
coffee
grounds;
swelling or
rapid weight
gain;
urinating less
than usual or
not at all;
nausea,
upper
stomach
pain, itching,
loss of
appetite, dark
urine, clay-
colored
stools, jaundi
ce (yellowing
of the skin or
eyes);
skin rash,
bruising,
severe
tingling,
numbness,
pain


Avoid drinking alcohol.
It may increase your
risk of stomach
bleeding.
Avoid taking Celebrex
together with other
NSAIDs such as
ibuprofen (Motrin,
Advil), naproxen
(Aleve, Naprosyn,
Naprelan, Treximet),
diclofenac (Arthrotec,
Cambia, Cataflam,
Voltaren, Flector Patch,
Pennsaid, indomethacin
(Indocin), ketoprofen
(Orudis), ketorolac
(Toradol), mefenamic
acid (Ponstel),
meloxicam (Mobic),
nabumetone (Relafen),
or piroxicam (Feldene).
Ask a doctor or
pharmacist before using
any other cold, allergy,
or pain medicine.
Medicines similar to
celecoxib are contained
in many combination
medicines. Taking
certain products
together can cause you
to get too much of a
certain type of drug
Check the label to see if
a medicine contains an
NSAID (non-steroidal
anti-inflammatory drug)
such as aspirin,
ibuprofen, ketoprofen,
or naproxen.
Avoid exposure to
sunlight or tanning
beds. Celebrex can
make you sunburn more
easily. Wear protective
clothing and use
sunscreen (SPF 30 or
higher) when you are
outdoors.

Page 61 of 67














Drug Name Doze Indications

Actions Side Effects Adverse
Reactions
Nursing
Responsibilities

Generic name:

Metoclopramide


Brand name:
Plasil


Classification:
Antiemetics


100mg
/tab
TID

Prevention
of
chemothera
py-induced
emesis. Trea
tment of
postsurgical
gastric
stasis. Treat
ment and
prevention
of postopera
tive nausea
and
vomiting.

Adjunct ma
nagement of
migraine he
adaches.

Blocks do
pamine
receptors
in
chemorece
ptor trigge
r zone of
the CNS.
Stimulates
motility of
the upper
GI tract
and
accelerate
s gastric
emptying.
Therapeuti
c Effects:
Decreased
nausea
and vomiti
ng. Decrea
sed sympt
oms of
gastric
stasis. Eas
ier
passage of
nasogastri
c tube into
small bow
el.
Restlessness
, dry mouth,
hypootensio
n/hypertensi
on.
CNS:
drowsiness,
extrapyramid
al
reactions, res
tlessness,
NEUROLEP
TIC
MALIGNAN
T
SYNDROM
E, anxiety,
depression,
irritability,
tardive
dyskinesia. C
V:
arrhythmias
(supraventric
ular
tachycardia,
bradycardia),
hypertension,
hypotension.
GI: constipati
on, diarrhea,
dry mouth,
nausea. Endo
:
gynecomasti
a. Hemat:
methemoglo
binemia,
neutropenia,
leukopenia,
agranulocyto
sis.

Instruct patient to take
metoclopramide as
directed. Take missed
doses as soon as
remembered if not
almost time for next
dose.

Pedi: Unintentional
overdose has been
reported in infants and
children with the use
of metoclopramide oral
solution. Teach
parents how to
accurately read labels
and
administer medication.

May cause drowsiness.
Caution patient to avoid
driving or other
activities
requiring alertness until
response to medication
is known.

Advise patient to avoid
concurrent use of
alcohol and other CNS
depressants while
taking this medication.

Advise patient to notify
health care professional
immediately if
involuntary
movement of eyes, face,
or limbs occurs.
Page 62 of 67































Drug Name Doze Indications

Actions Side Effects Adverse
Reactions
Nursing
Responsibilities

Generic name:
NaCl (Sodium
Cholride)


Brand name:
none




1Tab
TID x
5days

Preventing
or treating
sodium loss
due to
excessive
sweating or
dehydration.
It may also
be used for
other
conditions
as
determined
by your
doctor.
Sodium
chloride is
an
electrolyte
supplemen
t. It works
by
supplying
a source
of sodium
for the
body.
No
COMMON
side effects
have been
reported
with sodium
chloride.
Severe
allergic
reactions
(rash; hives;
itching;
difficulty
breathing;
tightness in
the chest;
swelling of
the mouth,
face, lips, or
tongue);
nausea;
stomach
pain;
swelling in
the hands,
ankles, feet,
or legs;
vomiting.
Instruct the patient to:

Take sodium chloride
by mouth with or
without food.
Take sodium chloride
with a full glass of
water (8 oz/240 mL).
Sodium chloride may
be dissolved in water to
make a solution for
drinking. Ask your
doctor for proper
mixing instructions.
If you miss a dose of
sodium chloride, take it
as soon as you
remember. Continue to
use it as directed by
your doctor or on the
package label.

Page 63 of 67












Drug Name Doze Indications

Actions Side Effects Adverse
Reactions
Nursing
Responsibilities

Generic name:
Ascorbic Acid


Brand name:
Vitamin C

Classification:
Vitamin



500mg
/tab
BID x
1week
Ascorbic
acid
(vitamin C)
is used to
prevent or
treat low
levels of
vitamin C in
people who
do not get
enough of
the vitamin
from their
diets.
Vitamin C
plays an
important
role in the
body. It is
needed to
maintain
the health
ofskin,
cartilage,
teeth,
bone,
and blood
vessels. It
is also
used to
protect
your
body's
cells from
damage. It
is known
as
an antioxi
dant.

Essential
vitamin
believed
to be
important
for
synthesis
of cellular
componen
ts,
catechola
mines,
steroids,
and
carnitine.
Diarrhea,
nausea,
vomiting,
abdominal
cramps/pain
, or
heartburn m
ay occur.
painful
urination,
pink/bloody
urine.

rash, itching/
swelling
(especially of
the
face/tongue/t
hroat),
severe dizzin
ess, trouble
breathing.
Explain that taking this
product with foods high
in iron will enhance
absorption of iron.

Explain to any patient
scheduled for glucose
studies that product
should not be taken for
at least 48 to 72 h
before test.

Inform patient that
abruptly stopping high-
dose therapy may lead
to loosening of teeth
and bleeding gums.

Page 64 of 67













Drug Name Doze Indications

Actions Side Effects Adverse
Reactions
Nursing
Responsibilities

Generic name:
Mefenamic
Acid


Brand name:
Ponstan

Classification:
Nonsteroidal
anti-
inflammatory

500mg
/tab
BID x
1week
Mefenamic
acid is used
for the
short-term
treatment of
mild to
moderate
pain from
various
conditions.
It is also
used to
decrease
pain and
blood loss.
inhibition
of
cyclooxyg
enase
activity
and
prostaglan
din
synthesis.
Upset
stomach,
nausea,heart
burn,
dizziness,
drowsiness,
diarrhea,
and headach
e
fainting,
persistent/sev
ere headache,
hearing
changes
(e.g., ringing
in the ears),
fast/poundin
g heartbeat,
mental/mood
changes,
stomach
pain,
difficult/pain
ful
swallowing,
swelling of
the
ankles/feet/h
ands,
sudden/unex
plained
weight gain,
vision
changes,
unusual
tiredness.
Closely monitor BP
during initiation and
throughout the course
of treatment. Monitor
for signs and symptoms
of GI bleeding. Patients
on long-term treatment
should have their CBC
and a chemistry profile
checked periodically.
Carefully monitor
patients receiving
mefenamic acid who
may be adversely
affected by alterations
in platelet function,
such as those with
coagulation disorders or
patients receiving
anticoagulants. If
clinical signs and
symptoms consistent
with liver or renal
disease develop,
systemic manifestations
occur (eg, eosinophilia,
rash), or abnormal LFTs
persist or worsen,
discontinue mefenamic
acid.
Page 65 of 67

Ongoing Appraisal
The patient was admitted last January 28, 2014 at Philippine
orthopedic Center with a chief complaint of mass at the right knee. Upon admission
he was diagnose of Osteosarcoma Proximal Tibia status post amputation at the above
the right knee and Pulmonary Metastasis. On the same day, she complied with the
laboratory examinations that are needed for his condition. As a student nurse we do
the following intervention.
Day 1
February 11, 2014
The patient was seen lying on bed. This is the first day we handled
the patient so we established rapport to gain his trust and make him feel safe and
comfortable. We took his vital signs and we assess him from head to toe, these were
the datas that use to get a baseline for further intervention we also interview the
patient during the interaction the patient verbalized Ang dami ng tumutubong bukol
sa katawan ko, Mamamatay na ko at wala na rin akong silbi as a student nurse we
encouraged him to always pray and dont lose hope and also the patient verbalized
headache so we advised him to position himself on his preferred position and to take
adequate rest. When assessing the patient, we asked the father if the patient can move
or can ambulate his left leg, the father verbalized hindi niya maigalaw pero
maynararamdan siyaso we advised and encouraged the father to massage and
exercise to prevent embolism.
RR: 21 PR: 83 Temp: 36. 8

Day 2
February 12, 2014
For the second day of our duty we visited again the patient and took
his vital signs to know if theres a difference result from the first day that we took his
vital signs and we also assess him again if theres any changes and improvement.
Were not able to talked to the patient due to his condition he is slept to gain
energy.We asked the father if the patient perceptionon his condition is still the same
from the first day. The father verbalized hindi na gano tulad noong una, pinababasa
ko sya ng bible.
RR: 24 PR: 80 Temp: 37.4



Page 66 of 67

Discharge planning methods


Medications

Coamoxiclav 625 mg tab TID x 1 week for infection
Celecoxib 200 mg tab BID prn for fever
Vit. C 500mg/ tab BID x1 week




Environment and
exercise

-Maintain quiet, pleasant, environment to promote
relaxation. Provide clean and calm environment.

-Encourage the client to continue exercising and bending
this promote circulation of the blood and relaxation.



Treatment

Continue home medications. For the follow up check up
repeat





Health teachings



- Life style change
- Provide a written and oral instructions about the
activity, diet recommendation, medication and
follow up visits


Out Patient

Patient was advise to go back in the hospital in a specific
date to have a follow up check up after discharge consult
doctor for any problems or complication in counter






Diet




Diet as tolerated


Spiritual Nursing

Providing presence
Supporting religious practices
Assisting clients with prayer






Page 67 of 67

Bibliography:
Doenges M., Moorhouse M., Murr A. (2010) Nursing Care Plans 8th Edition.
Davi's Nursing Resource Center
Pillitteri A. (2010) Maternal and Child Health Nursing: Care of the
Childbearing and Childbearing Family 6th Edition. Lippincott Willians and
Wilkins
Weber J., Kelley J. (2010) Health Assessment in Nursing 4th Edition.
Lippincott Willians and Wilkins
Wilson, Shannon, Shields (2012) Nurse's drug guide. Pearson
October 2010 - Volume 40 - Issue 10 - p 3439, doi:
10.1097/01.NURSE.0000388308.45275.3e, Feature: CE Connection
Dott. Ciammaichella M. M., Dirigente Medico, Responsabile UAS Trombosi
Venosa Profonda ed Embolia Polmonare, Responsabile CDF BLSD IRC
Emersan Lateranum, U.O.C. Medicina Interna I per lUrgenza, (Direttore:
Dott. G. Cerqua), ACO S. Giovanni - Addolorata - Roma
Brunner & Suddharths Textbook of Medical and Surgical Nursing, 11
th

Edition
Davis Textbook, Nursing Care Plans, Eighth Edition

Online Resources:
Retrieved Date: March 10, 2013
http://www.pathology.med.umich.edu/bloodbank/manual/bbch_6/
Retrieved Date: September 17, 2013
http://www.scribd.com/doc/19469217/Case-Study-osteosacoma
http://www.aafp.org/afp/2011/0315/p719.html