Demographic Profile:
Name: Allis Babcocks
Age: 46 years old
Sex: Female
Civil Status: Married
Nationality: American
Religion: Roman Catholic
Educational Attainment: College Graduate
Occupation: Teacher
Chief Complaint: Occasional mild pain and growing lump in the right breast, upper outer quadrant
History:
Patient presented to the hospital with a 4-month history of occasional, mild, right breast pain, rated it as 3 our of 10 and temporarily relieved with analgesics. 2 months PTA, patient noticed a small, immovable lump on the upper, outer quadrant of the breast. 1 week PTA, the lump has not resolved and became more prominent which prompted admission
Medical History:
No comorbidities. No allergies
Gynecologic History:
- Has 1 child, delivered via NSVD @2007, at age 32
- Menarche at age 11
- Regular menstruation with occasional dysmenorrhea
- Family History:
- Mother diagnosed with breast cancer at age 49 and died at age 67 from reoccurrence of cancer
Medications:
- Ibuprofen
- Multivitamins
Cues/Evidences
⦁ Patient verbalized "I'm worried about how my health condition will affect my Life, job, and family.
⦁ Rates breast pain as 4/10, sharp in nature that occurs abruptly, but sometimes radiate throughout the whole right breast.
Vital signs T= 36.5, P R=80, RR=16, BP= 110/80, 02 sat- 98% Height= 157 cm,
Weight 60 kg
BIB I: 24.3
⦁ Unilateral nipple retraction and some skin puckering noted on right breast; no nipple discharges
⦁ Right breast mass palpable on upper-outer quadrant, hard, non-mobile with irregular edges
⦁ No masses on the axilla. No lymphadenopathy.
⦁ Lung, bowel, heart sounds unremarkable
Laboratory Findings
⦁ Mammogram revealed dense breast tissue and 1.7 x 2.0 x 1.9 cm solid mass with irregular borders on
right, upper-outer quadrant breast.
⦁ Core biopsy pathologic examination showed a Grade I, invasive ductal carcinoma;
⦁ Immunohistochemistry: ER/PR positive, and HER-2 negative.
⦁ MRI and biopsy confirmed the presence of malignancy.
⦁ CBC unremarkable.
Medical Diagnosis:
Stage IA, invasive ductal carcinoma; early stage breast cancer
Treatment:
Total mastectomy of right breast, followed by Hormone therapy: Tamoxifen.
Surgical Team
Surgeon: Dr. Mama Bear
Anesthesiologist: Dr. Sevo Flour
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What are your immediate preop nursing responsibilities for this patient?
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