NURSING PROCESS:

THE PATIENT WITH A BONE TUMOR

OSTEOSARCOMA
Ns. Heri Kristianto, SKep.,MKep.,Sp.Kep.MB

Onset

and symptoms
During the interview, the nurse notes the patients
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 patients mobility and ability to
perform ADLs

Pengkajian

Locus in bone

1%

Metaphyseal
lesions

9095%

Diaphyseal
lesions

211%

Metaphyseal
lesions
extending to
epiphysis

7588%

Primary
epiphyseal
lesions

<1%

Locus in
skeleton

Knee

5075%

Femur

4555%

Tibia

1620%

Humerus

1115%

Lokasi gambaran radiologis

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

NURSING DIAGNOSES

Potential complications may include the

following:
Delayed wound healing
Nutritional deficiency
Infection
Hypercalcemia

COLLABORATIVE PROBLEMS/
POTENTIAL COMPLICATIONS

The major goals for the patient include

Knowledge of the disease process and
treatment regimen
Control of pain
Absence of pathologic fractures
Effective patterns of coping
Improved self-esteem
Absence of complications

Planning and Goals

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

Nursing Interventions

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.

PROMOTING UNDERSTANDING OF THE

DISEASE PROCESS AND TREATMENT REGIMEN

 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

RELIEVING PAIN

 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.

PREVENTING PATHOLOGIC
FRACTURE

Weight-bearing exercise is
physical activity in which
muscles and tendons
apply tension to bones,
stimulating them to
produce more bone tissue.

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 COPING SKILLS

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 ones life.

PROMOTING SELF-ESTEEM

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.

MONITORING AND MANAGING

POTENTIAL COMPLICATIONS

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.

Inadequate 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

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

Osteomyelitis and Wound

Infections

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).

Hypercalcemia

PROMOTING HOME AND COMMUNITY-BASED 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

Teaching Patients Self-Care

Frequently,

arrangements are made with a home health

care agency or home care supervision and follow-up.
The home care nurse assesses the patients and familys
abilities to meet the patients 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

Continuing Care

Hospice care

Expected patient outcomes may include:

Describes disease process and treatment regimen
a. Describes pathologic condition
b. States goals of the therapeutic regimen
c. Seeks clarification of information

Achieves control of pain

a. Uses multiple pain control techniques, including
prescribed medications
b. Experiences no pain or decreased pain at rest, during
ADLs, or at surgical sites

EXPECTED PATIENT OUTCOMES

Experiences no pathologic fracture

a. Avoids stress to weakened bones
b. Uses assistive devices safely and appropriately
c. Strengthens uninvolved extremities with exercise
Demonstrates effective coping patterns
a. Verbalizes feelings
b. Identifies strengths and abilities
c. Makes decisions
d. 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 home

Complies 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 appointments
Reports occurrence of symptoms or
complications. Maintains or increases body
weight

Caring