MUSCULOSKELETAL TUMORS

Objectives

Discuss nursing care for patients with musculoskeletal tumors.

Describe complications of treatment, including chemotherapy, radiation and surgery.

Overview and Pathophysiology

Tumor-like Lesions

Benign Tumors

Malignant Tumors

#1) Mr. A has just been diagnosed with an osteosarcoma. He shows an understanding of his treatment options when he states:

a) “I accept that I have to lose my leg.”

b) “I.m glad they can take out the cancer with such a small scar.”

c) “The chemotherapy before surgery will shrink the tumor.”

d) “This tumor is related to the colon cancer I had 6 years ago.”

#1 Answer: c)

Rationale: Chemotherapy and radiation are utilized prior to surgery to shrink the tumor and improve chances for limb salvage.

ASSESSMENT

What is “chief complaint”?

What modalities have been attempted?What beliefs?What support?

Diagnostic Tests

A/P and lateral x-ray Suspicious lesion

CT and/or MRI

X-ray/chest CT to rule out mets

Bone scan

Lab studies

Biopsy Open, Closed, Excisional

Arteriogram

Non-Surgical Interventions: Chemotherapy

Shrink primary tumor, facilitate resection

Destroy or shrink pulmonary metastasis/micrometastasis

Evaluate efficacy of cytotoxic drugs preoperatively

Chemotherapy

Types of drug

Routes of administration

Side Effects

Non-Surgical Interventions: Radiation Therapy

Adjuvant bone

Palliative bone

Adjuvant soft tissue

Brachytherapy

Neuron beam therapy

Surgical Interventions:Considerations

Amputation vs Limb Preservation

Resection / Reconstruction

#2) Mr. A has just undergone a below-the-knee amputation. During his postoperative course, measures to prevent flexion contractures of the proximal joint include:

a) placing bed in reverse trendelenburg.b) encouraging side lying position on affected side at

least t.i.d.c) placing pillow under his thigh.d) instructing him to maintain leg in neutral

rotation.

#2 Answer: d)

Rationale: Instruct Mr. A to maintain leg in neutral rotation, as other positions would not be beneficial, or actually lead to flexion contracture.

Nursing Diagnoses

Outcomes

Interventions

#3) Mr. Q, age 50, is preparing for removal of a liposarcoma with reconstructive surgery. Upon discussing pain management, Mr. Q states he had PCA-morpine after a prior surgery, but he is concerned he will become addicted if he uses it again. He takes one oral non-narcotic analgesic at bedtime & no other meds. An appropriate response would be:

a) “Maybe you should talk to the M.D. about Demerol PCA.”b) “Please tell me more about why you think you’ll become

addicted.”c) “I don’t think you should worry about addiction at your age.”d) “Would it help if we gave you morphine IM rather than a

PCA?”

#3 Answer: b)

Rationale: you need to discuss with the patient his misconception regarding pain management.

Pain:Barriers to Cancer Pain

Management

Problems related to:Healthcare professionalsPatientsHealthcare system

ABCDE Approach to Pain

A = Ask / Assess

B = Believe patient & family

C = Choose options

D = Deliver interventions

E = Empower / Enable

Nursing Diagnosis

Impaired physical mobility

Alteration in comfort

Outcome

Patient ambulates independently unless bedrest warranted

Patient verbalizes decreased or relieved pain

#4) Mr. J has been receiving preop chemotherapy & develops stomatitis. Dietary suggestions to help alleviate this discomfort would include:

a) orange juice mixed with protein powder.

b) spaghetti marinara.

c) mashed potatoes with butter.

d) raw vegetables.

#4 Answer: c)

Rationale: All other choices would exacerbate stomatitis because they are not bland.

Nursing Diagnosis

Self-care deficit

Ineffective individual & family coping

Alteration in sexuality

Outcome

Promote self-care & ability to carry out ADLs

Facilitate use of + coping skills

Patient/s.o. find means t express sexuality

#5) Mrs, M, age 30, has been diagnosed with osteosarcoma of the pelvis. Which of the following statements indicate her understanding of the reproductive issues which occur during chemo?

a) “I will never be able to have a baby.”

b) “My menstrual periods will remain regular.”

c) “I am worried my cancer will spread if I have sex.”

d) “My husband will continue to use condoms.”

#5 Answer: d)

Rationale: During chemotherapy, females undergo irregular menstrual cycles & infertility. However, conception is still possible & birth control is to be used during sexual intercourse to prevent complications.

Nursing Diagnosis

Alteration in skin integrity

Alteration in emotional integrity

Outcome

Skin integrity remains intact

Patient verbalizes feelings freely

Perioperative Considerations

Pain management

Anemia

Wound healing

Anxiety / Loss / Depression

#6) Jim, age 15, is about to undergo surgery for a 4cm. X 4cm. lesion following radiation therapy. You realize he will be at risk for a deficit in wound healing due to:

a) prior radiation therapy.

b) large area of resection.

c) his father’s hx of wound healing problems.

d) he doesn’t like to eat breakfast.

#6 Answer: a)

Rationale: Radiation therapy puts patients at greater risk for wound healing problems.

Bony Mets & Pathological Fractures

Summary

“Life over limb”

“Communication is key”

“Caring for the patient with a musculoskeletal tumor can combine the ‘acute’ and ‘chronic’ aspects of nursing”