MALIK SAEFUL BSN-3A

NURSING CARE PLAN

Cues

Nursing Diagnosis

Scientific

Objectives

Nursing Interventions Rationale

Evaluation

The client said it was

Impaired physical

Explanations
Osteosarcoma is a

Short Term:

1. Assess the level of

Short Term:

difficult to move.

mobility related to

primary malignant

After 3-4 hours of

immobilization

patient

After 3-4 hours of

Objective data: The

muskuluskletal

bone tumors are the

nursing

caused by edema

movement and

nursing interventions,

client looks impaired

damage, pain, and

most common and

interventions, the

and the patient's

plan exercise ,

the patients

coordination;

amputation.

often fatal and can

patients respiration

perception of

The patient

respiration will

decreased muscle

occur as a

will improve and pain

immobilization.

stated

improve and pain will

strength, control and

secondary

will be relieved.

R /: The patient will

understanding

be relieved.

mass.

metastases from

restrict the

of individual

1. To know

extremity limb in

Long Term:

movement as one of

situations,

Long Term:

50% of cases.

After 3 4 days of

perception

treatment

After 3 4 days of

Usually found on the

nursing

(perception are not

programs, and

nursing interventions,

former site of

interventions, the

proportional).

security

the patient will

radiation or more

patient will maintain

2. Encourage

often as a

a pain.

participation in

measures,
2. To increase

broadcaster in

recreational activities

Paget's disease.

(watching TV,
reading newspapers,
etc.).
R /: Provides the

activity of the
patient behind
relive of the
injury, The
patient seemed
to participate in

maintain a pain.

MALIK SAEFUL BSN-3A

opportunity to

training

expend energy,

programs /

focus, improve the

shows

patient's sense of

willingness to

self control and help

participate in

in reducing social
isolation.
3. Instruct the patient
to perform active and
passive exercises on
the injury or not.
R /: Increases blood
flow to the muscles
and bones to
improve muscle
tone, maintain joint
mobility, prevent
contractures /
atrophy and
reapsorbsi Ca
unused.

activities,
3. To get more
exercise from
muscle
stiffness and
more recovery
of the pain

MALIK SAEFUL BSN-3A

NURSING PRIORITIZED
Rank
1

Nursing Diagnosis
Impaired physical mobility related to musculoskeletal

Justification
Bone pain is the most common symptom found in the process of metastasis to bone

damage, pain, and amputation.

and is usually the initial symptoms are recognized by the patient. Pain arising from
stretching the periosteum and the endosteum nerve stimulation by tumor. The pain
can be intermittent and more pronounced at night or while resting.
The presence of bone metastases can cause bone structure becomes more fragile
and at risk for fracture. Sometimes fractures arise before other symptoms. Areas are

Activity intolerance related pain Chronic

often fractured long bones in the upper and lower extremities and spine.
Sensory nerves bring information about pain, heat, cold and other sensory
phenomena to the spinal cord from various parts of the body. At least two types of
nerve fibers are thought to carry the majority of pain messages to the spinal cord
Chronic pain is a controversial topic, and doubts have been raised regarding its
diagnosis and treatment as a clinical condition (e.g., CRPS, fibromyalgia). During the
past twenty years or so, however, tremendous advances have been made in our
understanding of the peripheral and central processes involved in chronic pain

Ineffective breathing pattern related to musculoskeletal

conditions.
Alteration on the clients O2:CO2 ratio due to decreased absorbed oxygen and poor

impairment

gas exchage related to presence to exudates on the alveolar spaces causes the body
to cope by increasing respiratory rate or by hyperventilation. The increase in
respiratory rate is elicited to cause an increase in the tidal volume of air that in
inspired in order to absorb more oxygen. The increase in respiratory rate may need

MALIK SAEFUL BSN-3A

the assistance of accessory muscle that would be evident by the rising and falling of
the shoulders during inspiration and expiration.