Documenting Clinical Findings

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  1. Describe the specific ways of documenting clinical findings from a female breast examination. Include the ten characteristics and explain each one using the guidelines from the “Normal Range of Findings” in Jarvis (2016), p. 400. Why is this documentation important?

During female breast examination, the following findings must be documented: patients concerns which includes health history questions regarding family history, age, actual and perceived risk, and reproductive history. Findings on amount of pain if any, presence of lump, nipple discharge, and rashes around the breast, any swelling, dimpling, nipple changes, and venous pattern. Third, a plan of action should be documented indicating the following steps for the normal or abnormal results. In case of abnormal results, any referrals that have been made should be included in the document. Patient education plan, which includes stressing the importance of adherence in, follow up, emphasis on rescreening, and breast self-exam must then be documented. The final step is to document results notification with details of the tests and procedures undertaken. Electronic documentation is most appropriate for clinical findings from a female breast examination since storing information electronically makes it easily accessible especially if needed urgently.

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The document should clearly indicate the person who documented the data. It should be legible meaning that it should be readable and with identified signatures. The information should be contemporaneous meaning that it should be documented in a timely manner and any delays should be justified. The document should be original or the investigator should have original source document. The information should be accurate, and be factual. The document should demonstrate the necessary attributes consistently. The information should be credible by being based on reliable and real facts. The document should be easily accessible, available and retrievable for review if need be. Moreover, the document should be complete. It is important to document clinical findings such information is useful in determining treatment in case of any abnormalities. Moreover, good documentation on clinical findings is useful in referrals in case of later abnormalities on female breasts.

  1. What are abnormal clinical findings on a male breast exam?

On a male breast exam, the following abnormal clinical findings may be identified: Breast lump or mass which is painless , enlarged lymph nodes especially under arms or around the collar bone , enlarged liver, rare nipple discharge or bleeding , irritation of the nipple, or ulcerated nipple.

  1. What breast self-examination (BSE) education would you provide utilizing evidence-based practice guidelines?

Based on information from the National Cancer Institute and from American Cancer Society, a monthly breast self-exam is recommended for breast cancer’s early detection. Women should look for changes in their breasts and if there is any, they should consult doctors. However, it is also very important for women to seek other screening practices such as mammograms in early detection of breast cancer for effective treatment.

Explain the importance of teaching testicular self-examination (TSE) as health promotion during assessment. Include the ages of the males TSE should be taught.

Cancer of testes is relatively uncommon. However, it is a potentially fatal condition. Early diagnosis improve prognosis of its victims. Testicular self-examination is useful in early detection of a tumor that is associated with testicular cancer. It is therefore important to educate people on how to perform testicular self-examination during assessment in order to promote health especially for potential victims. Early detection of tumor in testes is associated with higher rates of treatment success that late detection. Moreover, testicular is the commonest malignancy in young men, and therefore, it is necessary to educate men aged 20 to 35 years on techniques for self- examination with an aim of early detection for effective treatment.

According to American Nurses Association on standards of practice, it is the duty of nurses to teach people about health with a purpose of health promotion. Enlightening men on testicular self-examination will help in early detection of testicular cancer linked to effective treatment promoting health in the society. Although Sam and David have been able to make huge steps towards surviving with testicular cancer, many people have died from the diseases yet the death could have been avoided with earlier detection. It is thus important to educate males of testicular self-examination for early detection to increase the chances of survival as in the case of the two survivors.

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Documenting Clinical Findings. (2019, Oct 10). Retrieved February 7, 2023 , from

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