How To Assess Problems With The Breasts, Genitalia, Rectum, And Prostate. Nursing Assessment

How To Assess Problems With The Breasts, Genitalia, Rectum, And Prostate. Nursing Assessment

This essay is about a 45-year-old female that came with a history of a solid non-movable mass to her right breast that has been in the same are for over 2 years. The patient did not think that it was bad since she is not due for a Mammogram. The essay examines the subjective and objective data, appropriate diagnostics, and if I would reject or accept the current diagnosis.

Additional Information in the Subjective Portion

The subjective portion of the assessment is inadequate. Additional questions should be asked to understand better the client’s problem. Some of the needed questions include those related to whether the lump has been changing in its color, recent treatment for any breast infection, presence of an discharge, and if there has been a change in the contours of the lump.  The other question entails finding out if the patient is postmenopausal or not. The client in the case study is highly likely to be postmenopausal, which translates into the potential of the lump being cancerous. Information about a potential history of trauma should also be obtained. Information about the patient’s sexual life should also be obtained (Lynn, 2022). Besides, information about family history of chronic illnesses such as breast cancer should have been included, since it predicts the risk of cancer in the family.

Additional Information in the Objective Portion

The objective portion of the assessment is also inadequate. Additional objective data should be obtained to accurately diagnose the client’s problem. One of them is measuring and reporting the diameter of the lump. Information about the appearance of the lump, breast, and skin should also be provided to guide in the diagnosis process. Information about the appearance of the anterior chest wall is also important. This includes any signs and symptoms of an additional pathology such as chest in-drawing and abnormal curvature of the chest wall. The objective data should also include the vitals such as temperature, blood pressure, pulse, respiratory rate, and oxygen saturation. A deviation of the vitals from the normal could indicate an underlying abnormality. The objective section should also provide information about any diagnostic or laboratory investigations done. The data would guide in developing an accurate diagnosis and treatment plan for the patient. The other objective data that should have been included relates to the findings of breast palpation (Ackley et al., 2021). This includes the texture, temperature, or edema and other abnormal findings noted by the healthcare provider.

Assessment Support

Subjective data supports the information given in the case study. Subjective data provides insights into the experiences of a patient with a disease. Nurses and other healthcare providers use subjective data to guide the potential diagnostics that should be requested to understand a patient’s problem. Information such as the patient reporting a lump in the same area for 2 years is subjective. The case study does not have objective data.

Diagnosis

Some of the exams and diagnostic tests that would be appropriate include tissue biopsy, breast examination, chest x-ray, and complete blood count. Tissue biopsy will help identify if the lump has cancerous cells or not. Mammography will help determine if the lump could be benign or malignant (Lynn, 2022). Chest x-ray will help determine if there is abnormal chest findings. Complete blood count will provide the basis of other laboratory investigations.

Accepting or Rejecting Current Diagnosis

I would reject the diagnosis. Adequate subjective or objective data have not been obtained to guide the diagnosis. Some of the differential diagnoses for the client include breast cancer, breast cyst, and fibroadenoma (Stachs et al., 2019; Vasei et al., 2019; Waks & Winer, 2019). Therefore, additional investigations should be undertaken to develop an accurate diagnosis.

Conclusion

In summary, subjective and objective portions of the case study are inadequate. Subjective data has only been used to support the diagnosis. I will reject the current diagnosis. Additional subjective, objective, and diagnostics should be undertaken to develop an accurate diagnosis.

References

Ackley, B. J., Ladwig, G. B., Makic, M. B. F., Martin