ACUTE PAIN

NURSING DIAGNOSIS: Acute pain related to bone neoplasm as evidenced by guarding

behavior, grimacing face with pain scale of 9/10, a blood pressure (BP) of 130/90, respiratory
rate of 23 bpm, limping and with a verbalization of “perme nagsakit detoy sakka’k…”

NURSING INFERENCE: In osteosarcoma, the activation of innate immunity within the

body stimulates the release of chemical mediators, thereby, promoting the granulocytes to
respond to the invading tumor, hence, systemic inflammation occurs. When inflammation
occurs, bone and soft tissues are damaged stimulating the local nociceptors in the periosteum
leading to bone pain.

NURSING GOAL: After 8-10 hours of rendering nursing interventions, the patient will be
able to report that the pain is controlled or relieved with a pain scale of 5-7/10, a blood
pressure (BP) of 120/80, respiratory rate of 12-20 bpm and with verbalization of “Haan unay
nga nasakit toy saka kon.”

Nursing Interventions Rationale

Provide non- pharmacological measures Promotes relaxation and helps refocus

such as massage repositioning and back attention.
rub: as well as diversional activities such
as music, reading and watching tv.

Encourage the use of stress management Enables client to participate actively in

skills and complementary therapies such
as relaxation techniques, visualization
guided imagery, biofeedback, laughter,
music, aromatherapy and therapeutic
touch.
non-drug treatment of pain and enhance
sense of control pain produces stress
and, in conjunction with muscle tension
and internal stressors, increases client’s
focus on self, which in turn increases the
level of pain.

Evaluate pain relief at regular intervals. This information helps establish realistic
expectations and confidence in own
 ability to handle what happens.

Encourage adequate rest periods. To prevent fatigue.

Emphasize the importance of a well- To promote relaxation.

ventilated area.

Emphasize minimizing movements and Unnecessary movements can aggravate

to remain still as possible. the pain.

Administer medications as indicated: To relieve pain and promote rest.

ibuprofen (Advil) or acetaminophen
(Tylenol)

Educate patient of pain management One of the most important steps toward
approach that has been ordered, improved control of pain is a better
including therapies, medication patient understanding of the nature of
administration, side effects, and pain, its treatment, and the role patient
complications. needs to play in pain control.

If patient has growing cancer pain, assist Support groups and pastoral counseling
patient and family with managing issues may improve the patient’s and family’s
related to death and dying. coping skills and give needed support.

Explain the importance of lifestyle Changes in activities such as work

modifications to effective pain routines, household, and home physical
management. environment may be required to promote
more effective pain management.

NURSING EVALUATION: After 10 hours of rendering nursing interventions, the patient

is able to report that the pain is relieved with a pain scale of 7/10, a blood pressure (BP) of
120/80, respiratory rate of 12 bpm and verbalization of “Haan unay nga nasakit toy saka
kon.” Thus, the goal is met.
IMPAIRED PHYSICAL MOBILITY

NURSING DIAGNOSIS: Impaired Physical Mobility related to musculoskeletal

impairment as evidenced by slowed movement with a verbalization of “medyo marigatan-ak
magna kasi adda nagtubo nga tumor ditoy sakak”

NURSING INFERENCE: In osteosarcoma, the activation of innate immunity within the

body stimulates the release of chemical mediators, thereby, promoting the granulocytes to
respond to the invading tumor, hence, systemic inflammation occurs. When inflammation
occurs, bones and soft tissues are damaged, thereby, leading to limping hence impaired
physical mobility

NURSING GOAL: After 2-3 weeks for rendering nursing interventions, the patient will be
able to maintain or increase strength and function of affected and compensatory body part
with a verbalization of “haan ak unay marigatan nga magnan.”

Nursing Interventions Rationale

Support affected body part or joint

using pillows, rolls, foot support and To maintain position of function
shoes

Instruct the use of siderails, For position changes, transfers and

overhead trapeze, roller pads, ambulation.
walker, and cane

Administer medication prior to To permit maximal effort and

activity as prescribed for pain involvement of the activity

Schedule activity with adequate rest To reduce fatigue

periods during the day
 Collaborate with physical medicine To develop individual exercise and
specialist and occupational or mobility program, to identify
physical therapists in providing appropriate mobility devices, and
range-of-motion exercises, assistive limit or reduce complications of
devices, and activities such as immobility
ambulation and transfers.

NURSING EVALUATION: After 3 weeks for rendering nursing interventions, the patient
is able to increase strength and function of affected and compensatory body part with a
verbalization of “haan ak unay marigatan nga magnan.” Thus, goal is met.

Nursing Diagnosis: Fatigue related to decreased metabolic energy production secondary to bone
pain as evidenced by overwhelming lack of energy, inability to maintain usual routines, lethargy
and drowsiness.
Nursing Inference: In osteosarcoma, the body undergoes stress as it tries to cope with the
release of inflammatory cytokines (proteins) in the blood that can put extra stress on your joints
and muscles. The physical and emotional energy you use trying to deal with pain can make you
feel fatigued.
Nursing Goal: After 8-10 hours of rendering nursing intervention, the client will report
improved sense of energy as manifested by performing activities of usual routine and participate
in desired activities at level of ability.

Intervention Rationale

Restrict environmental stimuli, especially Vivid lighting, noise, visitors, numerous

during planned times for rest and sleep. distractions, and litter in the patient’s
physical surroundings can limit relaxation,
disturb rest or sleep, and contribute to
fatigue.

Assist with self-care needs when indicated; Weakness may make ADLs difficult to
keep bed in low position, pathways clear of
furniture; assist with ambulation. complete or place the patient at risk for
injury during activities.

Encourage patient to do whatever Enhances strength and stamina and

 possible (self- bathing, sitting up
in chair, walking). Increase activity level as enables patient to become more
individual is able.
active without undue fatigue.

Monitor physiological response to activity Tolerance varies greatly depending on the

(changes in BP, heart and respiratory rate). stage of the disease process, nutrition state,
fluid balance, and reaction to therapeutic
regimen.

Promote sufficient nutritional intake. The patient will need properly balanced
intake of fats, carbohydrates, proteins,
vitamins, and minerals to provide energy
resources.

Identify energy conservation methods such Being with the patient prevents the patient
as sitting and dividing ADLs into from getting harm during activities.
convenient segments. Assist with movement
or self-care demands as appropriate.
Weakness can make ADLs almost
not possible for patient to finish.

Aid the patient develop habits to promote Promoting relaxation before sleep and
effective rest/sleep patterns. providing for several hours of uninterrupted
sleep can contribute to energy restoration.

Make the patient aware about the signs and Changes in heart rate, oxygen saturation,
symptoms of overexertion with activity. and respiratory rate will reflect the patient’s
tolerance for activity.

Educate the patient and family about task Organization and management of time can
organization methods and time organization assist the patient save energy and avoid
methods. fatigue.

Nursing Evaluation: After 8 hours of rendering nursing intervention, the client was able to
report improved sense of energy as manifested by performing activities of usual routine and
participating in desired activities at level of ability. Thus, the goal is met.