NURSING PROCESS: THE PATIENT WITH A BONE TUMOR
The nurse asks the patient about the onset and course of symp-toms. During the interview, the nurse notes the patient’s under-standing 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 ten-derness. Assessment of the neurovascular status and range of motion of the extremity provides baseline data for future com-parisons. The nurse evaluates the patient’s mobility and ability to perform ADLs.
Based on the nursing assessment data, the major nursing diagnoses for the patient with a bone tumor may include the following:
· 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, percep-tion of disease process, and inadequate support system
· Risk for situational low self-esteem related to loss of body part or alteration in role performance
Potential complications may include the following:
· Delayed wound healing
· Nutritional deficiency
The major goals for the patient include knowledge of the disease process and treatment regimen, control of pain, absence of patho-logic fractures, effective patterns of coping, improved self-esteem, and absence of complications.
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 devel-opment of complications such as deep vein thrombosis, pul-monary emboli, infection, contracture, and disuse atrophy. The affected part is elevated to control swelling, and the neurovascu-lar status of the extremity is assessed.
Patient and family teaching about the disease process and diag-nostic and management regimens is essential. Explanation of di-agnostic tests, treatments (eg, wound care), and expected results (eg, decreased range of motion, numbness, change of body con-tours) helps the patient deal with the procedures and changes. Cooperation and adherence to the therapeutic regimen are en-hanced through understanding. The nurse can most effectively reinforce and clarify information provided by the physician by being present during these discussions.
Accurate pain assessment is the foundation for pain management. Pharmacologic and nonpharmacologic pain management tech-niques are used to relieve pain and increase the patient’s comfort level. The nurse works with the patient in designing the most ef-fective pain management regimen, thereby increasing the pa-tient’s control over the pain. 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 usu-ally adequate to relieve pain. In addition, external radiation or systemic radioisotopes may be used to control pain.
Bone tumors weaken the bone to a point at which normal activ-ities or even position changes can result in fracture. During nurs-ing 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.
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.
Independence versus dependence is an issue for the patient who has a malignancy. Lifestyle is dramatically changed, at least tem-porarily. 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 possi-ble amputation. It is helpful to provide realistic reassurance about the future and resumption of role-related activities and to en-courage 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 fam-ily throughout treatment encourages confidence, restoration of self-concept, and a sense of being in control of one’s life.
Wound healing may be delayed because of tissue trauma from surgery, previous radiation therapy, inadequate nutrition, or in-fection. The nurse minimizes pressure on the wound site to pro-mote circulation to the tissues. An aseptic, nontraumatic wound dressing promotes healing. Monitoring and reporting of labora-tory findings facilitate initiation of interventions to promote homeostasis and wound healing.
Repositioning the patient at frequent intervals reduces the in-cidence 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.
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. Nu-tritional supplements or total parenteral nutrition may be pre-scribed to achieve adequate nutrition.
Prophylactic antibiotics and strict aseptic dressing techniques are used to diminish the occurrence of osteomyelitis and wound in-fections. 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 chemo-therapy, 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 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, psy-chotic behavior).
Preparation for and coordination of continuing health care are begun early as a multidisciplinary effort. Patient teaching ad-dresses medication, dressing, treatment regimens, and the im-portance 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 as well as resources available for continuing care (Chart 68-10).
Frequently, arrangements are made with a home health care agency for home care supervision and follow-up. The home care nurse as-sesses the patient’s and family’s abilities to meet the patient’s needs and determines whether the services of other agencies are needed.
The nurse advises the patient to have readily available the tele-phone numbers of people to contact in case concerns arise.
The nurse emphasizes the need for long-term health super-vision 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.
Expected patient outcomes may include:
1) Describes disease process and treatment regimen
a) Describes pathologic condition
b) States goals of the therapeutic regimen
c) Seeks clarification of information
2) Achieves control of pain
a) Uses multiple pain control techniques, including pre-scribed medications
b) Experiences no pain or decreased pain at rest, during ADLs, or at surgical sites
3) Experiences no pathologic fracture
a) Avoids stress to weakened bones
b) Uses assistive devices safely and appropriately
c) Strengthens uninvolved extremities with exercise
4) Demonstrates effective coping patterns
a) Verbalizes feelings
b) Identifies strengths and abilities
c) Makes decisions
d) Requests assistance as needed
5) Demonstrates positive self-concept
a) Identifies home and family responsibilities that can be accomplished
b) Exhibits confidence in own abilities
c) Demonstrates acceptance of altered body image
d) Demonstrates independence in ADLs
6) Exhibits absence of complications
a) Demonstrates wound healing
b) Experiences no skin breakdown
c) Maintains or increases body weight
d) Experiences no infections
e) Does not experience hypercalcemia
f) Manages side effects of therapies
g) Reports symptoms of medication toxicity or compli-cations
7) Participates in continuing health care at home
a) Complies with prescribed regimen (ie, takes prescribed medications, continues physical and occupational ther-apy programs)
b) Acknowledges need for long-term health supervision
c) Keeps follow-up health care appointments
d) Reports occurrence of symptoms or complications
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