Rheumatoid arthritis

• Definition
RA is chronic systemic autoimmune disease characterized by
inflammation of connective tissue in synovial joints

Incidence
• Affecting all ethnic group
• Incidence increase with age (30 to 50 years)
• Increase incidence in those with family history of RA
Etiology
• Unknown
• Genetic (human leukocytes antigen DR1 and DR2) and envt.
• infection, smoking, obesity, abnormal immunoglobulin G
pathophysiology
• Genetic and environment factors trigger

• An antigen triggers the formation of an abnormal immunoglobulin G (IgG);

auto antibodies to this abnormal IgG. This auto antibodies known as
rheumatoid factors (RF)
• RF combine with IgG to form immune complexes that initially deposit on
synovial membranes or superficial articular cartilage in the joints
• Inflammatory response results
• Neutrophils are attaches to site of inflammation they release proteolytic
enzyme that damage articular cartilage this cause the synovial membrane
thickening
• Other inflammatory cells : T helper cells (CD4 cells), which stimulate cell
mediated immune response. Activated CD4 cells causes monocytes,
macrophages and synovial fibroblasts to secrete the proinflammatory
cytokines IL-1, IL-6 TNF ( tumor necrosis factors)
• Stimulate synovial cell to proliferate
• The increase synovial cells creates a PANNUS which is a thick swollen
synovial membrane with granulation or scar tissue made up of
fibroblast myofibroblast and inflammatory cells
• This pannus damage the cartilage and soft tissues and also erode
bone and directly grate against each other
• In addition to the inflammatory cells, increased protein (from the
break down protease secreted by synovial cells)on the surface of the T
cells
• Allow T cells to bind a protein on the surface of osteoclasts and to
start breaking down bone on the same time antibody enter in the
joint space
• Antibody =RF (which is an IgM antibody): IgM antibody that targets
IgG antibody , another antibody is anti Cyclic Citrullinated Peptide
antibody which targets citrullinated protein
• After the antibody binds its target they form an immune complexes
which accumulated synovial fluid
• This enzymatic cascade to promote joint inflammation and injury
• Chronic inflammation causes angiogenesis, which allowmore cells to
arrive the joint
• as disease progress multiple joints will affect on the both side of the
body and gradually destroyed
• This inflammatory cytokines when this escape through the blood
stream and reach multiple organ systems causing extra articular
problems.
 Clinical manifestations
• Non specific manifestation: Fatigue, anorexia, weight loss, generalised stiffness
• Joints : pain stiffness limited ROM, signs of inflammation
• Joint stiffness: experience after a periods of inactivity
• Morning stiffness last from 60 min to several hours
• Fingers : early stage –become spindle shape from synovial hypertrophy and thickening of
the joint capsule.
Tender, warm to touch, pain increase with motion,
tenosynovitis affects the extensor and flexor tendons the wrist producing
symptoms of carpel tunnel syndrome
Diseases progress: inflammation, fibrosis of joint capsule, muscle atrophy, tendon
destruction, subluxation
• Ulnar drift, swan neck, boutonniere deformities
• Hallus vagus
Extra articular manifestation
• Rheumatoid nodules appear subcutaneously firm tender granuloma type masses located
in the boney areas exposed to pressure as in the finger and elbow
• Lymph adenopathy
• Keratoconjunctivitis, episcleritis
• Sjogern’s syndrome
• Vascular lesion, pericarditis, myocarditis
• Amylodosis
• Myositis
• Rhematoid vasculitis
• Peripheral edema
• Peripheral neuropathy
• Raynaud’s phenomenon
• CTS
• Felty syndrome
• Intestinal fibrosis, pleuritis, caplan syndrome,
Diagnostic findings
• History and physical examination
• Analysis of blood (ESR and CRP, increased antinuclear antibody, anti-CCP),
synovial fluid (slightly cloudy, strawed colored fluid with many fibrin flakes,
increase in enzyme MMP-3, elevated WBC count)
• X-ray ( soft tissue swelling, bone demineralization, narrowed joint space,
articular cartilage destruction, erosion, subluxation and deformity)
• Tissue biopsy can confirm RA
• CT
• MRI
• Ultrasound ( detect early the joint changes and to conform he diagnosis)
Medical management
Pharmacological management
• DMARDs (disease modifying anti rheumatic drug): slow the disease
progression and decrease the risk of joint erosion and deformity
Antimalarial (hydroxychloroquine)
Gold compound (auranofin, gold sodium thiomalate)
Immunosuppressant (azathioprine cyclophosphamide)
• JAK inhibitor : tofacitinib for moderate to severe RA
• Biological response modifier: methotrexate
• TNF inhibitor : infliximab, golimumab,
• IL-1 receptor inhibitor: anakinra
• IL-1 receptor antagonist: sarilumab
• T-cell inhibitor: abataceb
• Antibiotics: doxycycline
Nursing management
• Health promotion
• Acute care
• Ambulatory care
• Rest
• Heat and cold therapy and exercise
• Patient and caregiver teaching
• Psychological support
Nursing diagnosis
• Chronic pain rt joint inflammation/ stiffness/ overuse/joint destruction
• Impaired physical mobility rt stiffness/ pain/ deformity
• Disturbed sleep pattern rt generalized musculoskeletal aching/ stress/
excessive fatigue/ stiffness/
• Disturbed body image rt chronic disease activity/ long term treatment/
inability to perform usual activities
BURSITIS
 Bursitis
• Bursae are fluid-filled sacs lined with the synovial membrane and contain a
small amount of synovial fluid. Located at the sites of friction such as b/w
tendons and bones and near the joints.
Definition:
• Bursitis is inflammation or irritation of a bursa sac. It is caused by repeated
pressure on an area or over use of joint too much, also it result from
repeated or excessive trauma or friction, gout, RA or infection.
Etiology
• Strenuous or repeated physical activity
• Injury or trauma
• Infection
• Underlying rheumatic conditions such as pseudogout and gout
• Inflammatory disorders such as rheumatoid arthritis, ankylosing
spondylitis, and systemic lupus erythematosus.
Risk Factors
• Aging
• Chronic medical problem
• Repetitive sports or activities
• Repetitive use of a same joint
• Improper posture
• Getting an infection that can spread to bursae, bones, and joints
• Injuries to the bursae
 Types
Prepatellar Bursitis
• Tears or damage to your kneecaps or knee bursae may cause swelling.
Other causes are:
• Sports-related activities
• Bending your knees repeatedly
• Staying on your knees for long periods of time
• Infection
• Bleeding in bursae
Prepatellar Bursitis
 Olecranon bursitis
• Repeatedly resting your elbows
on hard surfaces or a hard blow
to the back of the elbow can
cause this type of bursitis. It can
also be caused by infection or
gout.
Gout occurs when uric acid
crystals build up in the body. Gout
can result in tophi, or small
nodules, that can be felt within
the bursa.
 Types
Trochanteric Bursitis
Many things can trigger bursea of inflammation and pain in your hips.
These include:
• Lying on your hips for long periods of time
• Improper posture while sitting or standing
• Any disease that affects your bones, such as arthritis
• Injury
Retrocalcaneal Bursitis

• Running, jumping, or other repetitive activities can inflame the

bursae in your heels. Beginning a strenuous exercise without properly
warming up may also be a cause. Shoes that are too tight at the back
of the heel can make it worse as it rubs against the bursa.
Infectious (Septic) Bursitis
• Infectious, or septic, bursitis occurs when the bursa becomes inflamed due
to an infection from bacteria.
• This occur when bacteria are directly introduced into the bursa through a
wound in surrounding skin.
• Skin infections, such as cellulitis, may lead to infectious bursitis. Blood or
joint infections can also spread to the bursa and cause infectious bursitis.
• Symptoms of infectious bursitis are similar to those of noninfectious
bursitis.
• draw a sample of bursal fluid and use a bursal fluid analysis to test for
infectious bursitis.
• Bursa location in the body :- Elbow, Shoulder, Hip or thigh, Buttocks, Knee,
Achilles tendon or heel
Clinical manifestation
• Swelling, redness, and warmth in the area
• Tenderness or pain
• Stiffness
• Restricted movement.
• Fever (over 102°F)
• General illness
• Trouble moving the joint (limited ROM)
Diagnostic Evaluation
• Physical examination and full medical history
• Ultrasound scanning
• Blood tests
• Sample of the fluid in the affected bursae to rule out infection or
underlying conditions.
• X-ray of the affected area to rule out other problems that might be
causing pain
• MRI and ultrasound to study an image of joint.
Management
• Avoid activities that make it worse
• Rest and raise the affected area to restrict or stop the activity that has caused the
bursitis
• Ice packs applied to the area to reduce swelling and discomfort
• Wearing a support on the injured joint by compression dressing, brace, band, or
splint on the joint
• Reducing pressure on the affected area by wearing pads around the bursa and
well-fitted shoes for heel bursitis
• NSAIDs e.g., ibuprofen, naproxen
• Intra articular Cortisone (corticosteroid) injections
• The fluid may need to be aspirated from the affected bursa to relieve pressure.
Need antibiotics if aspirate infected fluid from infected bursa.
• Weight loss may be recommended for obese patient in order to help to relieve
pressure on the affected joint(s)
• Physical therapy or exercises to strengthen the muscles around the affected joint.
 SX management
• If bursal wall become thickened and continues to interferer the joint
function in this case Sx will done.
• Bursectomy surgical excision of bursae
• Surgical drainage
SYNOVITIS
 SYNOVIAL MEMEBRANE and FLUID
• Synovial membrane is a thin highly vascular membrane, pink in color,
smooth and shiny appearance. It is inner membrane of synovial joints and it
contains specialized cells (synoviocytes). It is lines capsule, covers exposed
osseous surfaces, tendon sheaths and bursa but does not cover the articular
cartilage, intra-articular disc/menisci.
• Its main function to produces synovial fluid. Synovial fluid is clear viscous
yellow fluid, (no fibrinogen), 0.5 mL of synovial fluid present in knee joint,
viscosity of the synovial fluid depends on concentration of hyaluronic acid,
• It consists of 96% of water and 4% of solutes with a specific gravity of 1.010
and pH of 7.3 to 7.6,
• It reduced in osteoarthritis and after trauma.
• Other function of synovial fluid are hold joints together, lubrication, cushions,
and nourishes.
 SYNOVITIS
• Synovitis is inflammation of the synovial membrane.
Etiology

• Overuse of the joint such as athletes

• Repetitive stress movement such as lifting or squatting
• Arthritis.
 Pathophysiology
• Synovitis formation of reactive inflammatory fluid → raised intra-
articular pressure → damaged synovial perfusion → formation of
synovial cysts constitutes an effective decompressive mechanism
cause joint instability → unilateral accumulation of fluid from the
inflamed joint. Cartilage loss eventually damages the joint surface
and leads to the stiffness and pain characteristic of all types of
arthritis.
• In arthritis, excessive growth of the synovium is part of an abnormal
immune response, where the body misidentifies its own natural
cartilage as a foreign substance that must be attacked. It causes
'boggy' joint swelling, overlying the affected joint is warm and red
due to increase in blood flow. The swelling is tender and painful.
 Clinical Manifestations
• Joint tenderness
• pain
• swelling
• hard lumps, called nodules.
• When associated with rheumatoid arthritis, swelling is a better
indicator than tenderness.
 Management
• Specific treatment depends on the underlying cause of the synovitis
• Anti-inflammatory drugs such as NSAIDs
• Injection of steroids may be done, directly into the affected joint
• Surgical management
• Synovectomy:- removal of the synovial membrane. It is done early in
the disease process when there is minimal bone and cartilage
destruction, but it does not cure the disease it may relieve symptoms
• sites of the surgery:- elbow, wrist and fingers. In knee the sx is done
less frequently bcoz knee replacement is usually done
 BONE TUMORS

Definition :
Bone tumor is an abnormal growth of cells with in the bone that may
be noncancerous (benign) or cancerous ( malignant)
Types : 2
Benign and malignant
Account for 3% all tumors
 BONE TUMORS

Risk factors
 Genetic disorders: Li-Fraumeni syndrome :- mutation of the p53 tumor
suppressor gene this develop several types of cancer like breast ca., brain
ca., osteosarcoma and type of sarcoma and Rothmund - Thomson
syndrome :-caused by abnormal changes in gene REQLA its result in short
and have skeletal problems and rashes
 Retinoblastoma – inherited disease, mutation of gene RB1 gene, risk of
developing soft tissue or bone sarcoma
 Paget’s disease –high risk of chondroma in childhood
 Radiation –ionizing
 Bone marrow transplantation – osteosarcoma due to BMT
WHO classification of B Ca.
• Cartilage tumors
• Osteogenic tumors
• Fibrogenic tumors
• Ewing sarcoma
• Fibrohistiocytic tumors
• Hematopoietic tumors
• Giant cell tumor (GCT)
• Notochordal tumor
• Vascular tumor
• Smooth muscle tumor
• Miscellaneous tumor/lesions
• Joint lesions
 Benign bone tumors
Type of benign bone tumors
• Nonossifying fibroma
• Unicameral or simple bone cyst
• Osteochondroma
• Gaint cell tumor
• enchondroma
• Fibrous dysplasia
• Chondroblastoma
• Aneurysmal bone cyst
• Osteoid osteoma
 1.Osteochondroma
• Most common primary benign bone tumor
• characterized by an over growth of cartilage and the bone near the end
plate of long bones
• more commonly found in pelvis scapula and long bones of the leg
Incidence : peak in 10-20 years age
Site : pelvis, scapula or metaphyseal part of the long bone, knee
Clinical manifestation
• Painless, hard, immobile mass,
• lower than the normal weight of the age
• soreness of muscles close to the tumor
• one leg or arm longer than another
• pressure or irritation with exercise
 Osteochondroma
Diagnosis
• X-ray
• CT scan
• MRI
Management
• asymptomatic osteochondroma - no treatment is necessary
• pain or neurological manifestations because of the compression
surgical removal is usually done and need regular screening
examination to detect progression to as soon as possible
 2. Enchondroma
• Enchondroma is common tumor of hyaline cartilage that develops in
hand, femur, tibia, humerus
• Intra medullary cartilage tumor usually found in cavity of a single
hand or foot bone
• Rarely transform to cancer
• If Painful –surgical intervention is needed
 3. Giant cell tumor (osteoclastomas)
• It arise in cancellous ends of arm and leg bones
• 10 % of this tumor are locally aggressive and may spread to lungs
(invade the local tissues and destruction)
• Occurs in young adult
• May undergone malignant transformation
• There are high rate of reoccurrence after surgery and chemotherapy
 Malignant bone tumors
• Musculoskeletal tumors are relatively rare and raise from supportive
and connective tissue cells (sarcoma:- is a malignant tumor that
develop in bone, muscle, fat, nerve and cartilage) and bone marrow
element (multiple myeloma)
Types
• Chondrosarcoma
• Ewing’s sarcoma
• Osteosarcoma
 a) Chondrosarcoma
• Malignant tumor composed of cartilage producing cells in the arm,
leg, pelvic bones of adults of 40-70 years of age
• That can be arise from benign tumor (osteochondroma)
• Wide surgical resection is done
• Tumor are rarely responds to radiation and chemothearapy
• Survival rate is depends on stage, size and grade of tumor
 b) Ewing’s sarcoma
• Ewing’s sarcoma develops in medullary cavity of pelvis and long
bones (upper and lower leg, pelvis, upper arm and ribs)
• Occurs in children and teenagers
• Managed with wide surgical resection, radiation and chemotherapy
• Survival rate is about 60%
 c) Osteosarcoma
Osteosarcoma is a extremely aggressive primary malignant bone tumors that rapidly
spreads to distant sites
• Most common primary bone cancer
• Occurs mostly in males, age between 10-25
• Most often in pelvic or bone of arms legs (metaphyseal region of the long bone) and it is
associated with Paget’s disease
C/M
• Gradual onset of pain
• Swelling especially around the knee
Diagnosis
• Confirmed by tissue biopsy
• elevated serum alkaline phosphate and calcium
• X ray
• CT scan or positron emission tomography (PET)
• MRI
 c) Osteosarcoma
Management
• Preoperatively NEOADJUVANT chemotherapy used to decrease the
size of the tumor b4 sx
• Limb lavage is only considered a clear 6-7 cm margin surrounds the
lesion and is contraindicated with major neurovascular involvement,
pathological #, invasion, extensive muscle involvement
• Adjuvant chemotherapy done after amputation or chemotherapy
• Chemotherapy include:- doxorubicin, cisplatin, cyclophosphamide
and methotraxates.
 Bone tumor clinical manifestation
Clinical Manifestations
• Cardinal symptoms are pain, swelling, and general discomfort,
• limited mobility and spontaneous fracture, fever, night sweats,
painless mass or obvious bone growth
• Varying degree of disability, weight loss, malaise with spinal
metastasis, spinal cord compression may
• Neurologic deficit:- progressive pain, weakness, gait abnormality,
paresthesia, paraplegia, urinary retention, loss of bowel or bladder
control.
Bone tumor clinical manifestation
• Pain-initially occur intermittently and only at rest, become more
intense, disturb sleep at night, intensification of pain is experienced
as a persistent and piercing pain.
• It becomes excruciating and intolerable, requiring opiate treatment.
• may experience radiating pain due to pressure on nerve trunks or
nerve plexuses.
• Swelling :- more rapidly in malignant tumors and very long duration
in benign neoplasms.
• It may cause skin changes, including tensed shining skin with
prominent veins, hyperthermia, striation of the skin and ulceration.
• Limitation of movement:- if the lesions close to the joint.
 Complications
• Delayed wound healing
• Nutritional deficiency
• Infection
• Hypercalcemia
• Muscle wasting, bone weakening
• Pathological fracture
• Temporary burn to the skin and fatigue from radiation therapy
• Nausea, vomiting, mouth sores, hair loss, and lowered resistance to infection from chemotherapy
• Infection of the surgical site and possible blood clotting
• disturbances from surgery
• Pain
• Spread of cancer to other surrounding tissue
Diagnostic Evaluations
• History collection
• Physical examination
• X-ray: Show the location, size and shape of a bone tumor.
• Bone scan: Radioactive material injected into a blood vessel and take scan to detect the
pathological changes in the bone.
• CT scan (computed tomography): Show the different angles of the bone
• MRI (magnetic resonance imaging): Use to create detailed pictures of areas of tumor.
• PET (positron emission tomography): Glucose injects into the vein and takes pictures of
tumor bone to study clear pathology. Because cancer cells use more glucose than normal
cells, the pictures can be used to find cancer in the body.
• Biopsy: Use to confirm the tumor type and stage
• Blood test: Alkaline phosphatase and elevated serum ALP, hypercalcemia (muscle
weakness, fatigue, anorexia, nausea, vomiting, polyuria, cardiac dysrhythmias, seizures
and coma).
 TNM classification
• TNM classification is an anatomically based system that records the
primary and regional nodal extent of the tumour and the absence or
presence of metastases.
• T category describes the primary tumour site and size
• N category describes the regional lymph node involvement
• M category describes the presence or otherwise of distant metastatic
spread
•
TNM Stage Grouping
• Stage I: All stage the bones are low grade and have not yet spread outside of the bone.
• Stage IA: T1, NO, MO, G1 to G2:tumor is 8 cm or less,
• Stage IB: T2 or T3, NO, MO, G1 to G2: the tumor is either larger than 8 cm or it is in
more than one place on the same bone.
• Stage II: Tumors have not spread outside the bone but are high grade.
• Stage IIA: T1, NO, MO, G3 to G4-: tumor is larger than 8 cm.
• Stage III: T3, NO, MO, G3 to G4. Stage III tumors have not spread outside the bone but
are in more than one place on the same bone. They are high grade.
• Stage IV: Tumors have spread outside of the bone.
• Stage IVA: Any T, NO, Mla, G1 to G4 or any T, and N, Mlb, G1 to G4: tumor has spread to
the lung.
• Stage IVB: Any T, N1, any Mlb, G1 to G4: tumor has spread to nearby lymph nodes or to
distant sites other than the lung.
 Management
• Systemic therapy: Chemotherapy, hormone therapy, immunotherapy,
e.g., interferon
• Local therapy: Radiation therapy and surgery
• Nutrition therapy: Provide foods high in protein, vitamins and folic
acid.
• Hormone therapy: Removal of the organs which produce hormones
which can promote the growth of certain types of cancer such as
testosterone in males and estrogen in females, or drug therapy to
keep the hormones from promoting cancer growth.
 Management
• Chemotherapy: Chemotherapy use of anticancer drugs to kill cancer cells, when
they have spread into the bloodstream.
• It is usually receiving a combination of anticancer drugs. most commonly used
drugs are doxorubicin (40 to 60 mg/ m²), cisplatin 75 to 100 mg/m². Carboplatin,
etoposide, Ifosfamide (1.2 g/m²), cyclophosphamide 10 to 15 mg/ kg
intravenous, 1 to 5 mg/kg oral), methotrexate (oral or IV), vincristine (1.4
mg/m²), usually several drugs like two or three drugs are given together, e.g.,
• combination is cisplatin and doxorubicin/ ifosfamide and etoposide / ifosfamide
and doxorubicin.
• Common side effects are :-
• nausea, vomiting, loss of appetite, hair loss, mouth sores.
• Ifosfamide and cyclophosphamide can cause hemorrhage cystitis and can be
prevented by giving a drug called mesna along with the chemotherapy.
• Cisplatin may cause neuropathy leading to problems with numbness, tingling and
even pain in the hands and feet. Nephropathy can also occur after treatment with
cisplatin.
 Management
• Radiation therapy: Used high dose X-rays to kill cancer cells and
shrink tumors. It may be given either before or after surgery. It may
be used in combination with surgery, if tumor is radiosensitive. It
may also be used for patients who refuse surgery. Radiation can also
reduce pain and decrease the chance of bone fractures.
• There are two types of radiotherapy such as intensity-modulated
radiation therapy (IMRT) and proton-beam radiation.
 Management
1. Intensity-modulated radiation therapy is an advanced form of
external beam radiation therapy. The radiation is delivered to the
tumor from several directions to reduce the amount of radiation that
goes through any one area of normal tissue.
2. Proton-beam radiation is a special form of radiation that uses
protons instead of regular X-rays to kill cancer cells. This allows a high
dose of radiation to be given to the tumor without hurting the normal
tissue around it. It is very helpful in treating skull base
chondrosarcomas and chordomas.
• Common side effects :- fatigue, loss of appetite, skin changes, ranging
from redness and hair loss to blistering and peeling.
 Surgical Management
• :- Removal of entire tumor with border of the tissue removed during surgery. It ranges from local
excision to amputation and disarticulation. It may include amputation, limb-salvage and
reconstructive surgery.
• Amputation-removes all or part of an arm or leg when the tumor is large and/or nerves and
blood vessels are involved. Amputation may be needed if removing all of the cancer requires
removing essential nerves, arteries, or muscles that would leave the limb without good function.
• Limb-salvage surgery-goal is to remove all of the cancer and still leave a working leg or arm. If a
cancer has grown into these structures, they will need to be removed along with the tumor. In
that case, amputation may be the best option.
• Reconstructive surgery-if the leg must be amputated mid-thigh, the lower leg and foot can be
rotated and attached to the thigh bone. The old ankle joint becomes the new knee joint. This
surgery is called rotationplasty
• Rotationplasty is a form of amputation, in which the patient's foot is turned upwards in 180° turn
and the upturned foot is used as a knee.
• Bone graft: Affected bone is removed; bone from elsewhere from the body is taken.
• Artificial bone: Affected bone is removed, putting an artificial bone.
Graft
• AUTOGENOUS GRAFT- SAME IND=same species
• ALLOGENIC another ind =same species
• XENO GRAFT-another species
• ALLOPLASTIC MATERIALS -synthetic material
 Management
• Targeted therapy: Imatinib drug is used to treat chordomas that have
spread or have come back after treatment. It may stop tumors growth
or shrink as little.
• Common side effects are mild and can include diarrhea, nausea,
muscle pain, itchy skin rashes and fatigue.
• Denosumab is a monoclonal antibody that binds to a protein called
RANK ligand. It may have injected under the skin, weekly for 4 weeks
and then every 4 weeks. It can take months to see tumor shrinkage.
• Its side effects are mild and can include body aches, headache, and
nausea. Maintaining good oral hygiene by flossing, brushing, making
sure that dentures fit properly, and having regular dental check-ups
may help prevent this.
 PAGET'S DISEASE/ OSTEITIS DEFORMANS
• Dr James Paget 1877
Definition:
• Is a chronic skeletal bone disorders in which excessive bone
resorption is followed by replacement of normal marrow by vascular,
fibrous connective tissues.
It is partial or complete involvement of a single or multiple bones by
exaggerated rates of restorative and osteogenic activity leading to
bony thickening and deformity.
New bones are larger, disorganized, and weaker
Nursing assessment
 Nursing diagnosis
• Acute or chronic pain rt pathological process and surgery

• Deficient knowledge rt disease process and therapeutic regimen

• Risk for injury: pathological fracture rt tumor and metastasis
• Risk for situational low self-esteem rt loss of body part
• Ineffective coping rt fear of the unknown perception of disease
process
• …..