Faulkner State Community College; Division of Nursing

NUR 201
Clinical Paperwork Data Sheet

Student Name___________________________________ Clinical Week_______________________________

Date _____________ Client Initials__________ Age _______________ Admission Date ______________

Instructor_______________________________________ Clinical Area ________________________________

Medical Diagnosis and Pathophysiology: (Be sure to list signs and symptoms). Please indicate your
source of information.

My patient has cancer of the left breast. Diagnosed as carcinoma in situ, which is a term used for early
stage cancer, when it is confined to the place where it started, and there is no further metastasis. Breast
cancer is the most commonly diagnosed cancer in women and is second only to lung cancer as a cause of
cancer deaths. Breast cancer is a malignant tumor that starts from cells of the breast. There is no single
known etiologic agent for breast cancer. Breast cancer can be attributed to multiple factors. Being an older
woman is the primary risk factor, although some women are at higher risk than others. As age increases,
so does risk. More than 85% of cases are diagnosed in patients over than 45 years of age. Women with a
family history of breast cancer, particularly a history of first-degree relative (mother, sister, or daughter) with
premenopausal breast cancer, have a three fold risk increase. Breast cancer is usually a sporadic rather
than an inherited or familial disorder. Many personal and environmental interactions are related to its
development. Known risk factors that increase risk include: exposure to high-dose ionizing radiation to the
thorax (especially before the age of 20), early menarche (before age 12), and late menopause (after age 50), a
history of previous breast cancer, nulliparity, and first birth after age 30. Other factors may include a diet
high in animal fats, obesity, alcohol consumption, and long-term estrogen replacement therapy. Early
detection by screening for breast masses involves a three-pronged approach: mammography, breast self-
examination, and clinical breast examination. Signs and symptoms include: a swelling of part of the breast,
skin irritation or dimpling, nipple pain or the nipple turning inward, redness or scaliness of the nipple or
breast skin, a nipple discharge other than breast milk, and a lump in the underarm area. Treatments
include: chemotherapy, radiation, and a mastectomy. My patient had a simple mastectomy (breast tissue
and usually nipple are removed), without axillary lymph node removal.

Medical-Surgical Nursing 5th Edition, Ignatavicius, Workman

American Cancer Society; http://www.cancer.org/

List and prioritize any secondary diagnosis that has been identified for your client (Based on your patient's
problems).

1. Blocked artery in brain

2. Coronary Artery Disease
3. Hypertension
4.
5.
6.
7.