This scenario highlights the importance of conducting a focused assessment of the breast and axillae. There are several important steps that have been conducted in this scenario. The first stage is to take a history from the patient, including onset and location information, as well as the duration of the issue, which has been done here. The history should consider family cases of breast cancer and could also include testing for the BRCA1 gene (Denton, 2013). The assessment also requires assessing for tenderness and changes to the skin around the breast and nipple area and making the same assessment of the axillae. Palpation is a useful technique which highlights whether there are any nodules or lumps in the breast or underarms (Neville, 2013). It is also important to note whether there are any issues with the nipples, including discharge and crusting.
The main factor relating to this diagnosis is that the patient has not gone for routine mammogram and thus it is difficult to know how long the breast lump as gone undetected. In cancer cases, this can make the cancer harder to treat, and it is important to diagnose the issue early for best outcomes (Anderson et al., 2015). The fact that the patient has a family history of breast cancer means that she should be going for check-ups regularly to ensure that she is protected from late-stage diagnoses. The patient also has the BRCA1 gene, which increases the probability of being diagnosed with cancer. The patient also has two daughters who may have inherited the gene. It could be useful if the daughters went for assessment for the gene as it can lead to breast and ovarian cancers that need to be caught early (Neville, 2013). The patient’s son is also at an increased risk of breast cancer.
The medical record should contain the information found in the assessment and a full history of the patient’s health. It should also contain details of the potential diagnosis and the treatment options that the patient has undergone.
The nursing diagnosis for this patient is breast cancer. This is a serious disease, but is readily treatable if the cancer is caught early. After the patient, has received treatment, the main nursing intervention would be to teach the patient how to conduct a full self-examination of the breast and axillae (Neville, 2013). Another nursing intervention is to get the patient in for regular screenings and mammograms for both breast cancer and forms of ovarian cancer that are linked to the BRCA1 gene. This can help to protect the patient from further diagnoses of cancer and keep her in remission should the treatment be effective.
The genetic findings of this care are interesting, particularly as the patient has two daughters. All three of her children should be aware of the signs and symptoms of breast cancer and be taught how to conduct a self-examination of the breasts as this can help to catch the cancer early (Neville, 2013). Jason should also be aware that breast cancer is possible in men. The patient herself should be educated in how she can detect whether the cancer is back, depending on the type of treatment that she receives. The teaching strategy here is to ensure that the patient and her family have all the information available to them that will help them to diagnose cancer early. The patient’s children can also be taught about the pros and cons of genetic testing for the BRCA1 gene and given counseling for the results, as it can be a difficult diagnosis to deal with psychologically (Maheu et al., 2015). The effectiveness of this evaluation can be evaluated by asking the patient and her family how they feel about breast cancer knowledge and observing how often that they come in for screening.