Question 2: When is the ideal time to complete a clinical breast exam?  What steps would you follow for concerning findings on the clinical breast exam? What age or risk factors indicate the need for a mammogram?

           Clinical breast exams are normally done during a woman’s annual vaginal exam.  Normally performed by a healthcare provider with proper training.  The National Comprehensive Cancer Network recommends that a trained provider carefully feel the breast, underarm and the breast bone area for any concerns such as a lump.  Clinical breast exams should be performed every one to three years starting at the age of 20 and every year starting at the age of 40 (Susan G. Komen Staff, 2018).

           The American Cancer Society does not recommend CBE for screening of breast cancer.  Clinical breast examinations lack the evidence to be an effective screening for breast cancer according to The American Academy of Family Physician’s.  The clinical breast exam is a time burden for clinicians, rather it is recommended that more time is spent on the comprehensive assessment of family history and counseling on mammograms and breast changes (Bredemeyer, 2016). 

           If there are abnormal findings during the CBE, it is important to follow with a mammogram or breast ultrasound to identify the concern, if there is a long family history and/or the patient is over 30 years of age. If the patient is under thirty with no family history the physician may decide to watch the area for growth or pain.  Normally that time frame is approximately one or two menstrual periods.  Once the concern is located, and deemed a true concern, biopsy and further testing will be needed.  It is important to note that most abnormal findings are found to be benign, however it is vital to pay close attention to changes in the area of concern and work with the physician to determine course (Bredemeyer, 2016).

           When a patient has a lengthy family history of cancer, either breast or other cancer, yearly mammograms are necessary to determine concerns early.  In recent years there is also Breast magnetic resonance imaging (MRI) that gives a three dimensional look of the breast, this test can also be used after a positive mammogram comes back (Susan G. Komen Staff, 2018).

           It is important to note that if there is a positive screen for breast cancer, it is important to receive a second opinion to ensure that it is not a false positive.  Normally a biopsy will be done to ensure the pathology.

References

Bredemeyer, M. (2016). ACS Releases Guideline on Breast Cancer Screening. American Family Physician, 711-712.

Susan G. Komen Staff. (2018, July 6). Clinical Breast Exam. Retrieved from Susan G. Komen: ww5.komen.org/breastcaner/clinicalbreastexam

 

Examine Your Barriers to Cultural Competence

1. Respond to the prompts below in full sentences.  Be sure to use standard English grammar and spelling:

• Assess your own barriers to cultural competence.
  • Have you overcome these?  If not, how do you plan to overcome them?
  • If you do not have barriers, why do you think you do not have them?

This is revised work. It has been reviewed and this are the instructor’s comments below. The paper itself is attached

  

                                       Comments from instructor

Competency 1 Assessment

You list several advantages of informatics, but do not discuss one issue that will be helped with informatics.

There is no discussion of the history of informatics.

The running head is formatted differently on the first page and is never bold. For sources with 1-2 authors, you must list them all every time you cite that source. For sources with 3-5 authors, you only list all the authors the first time, For subsequent citations only list the first author with et al. For sources with more than 5 authors, only list the first author with et al. every time you cite. References should not bold. Only sources that are cited in the paper are included in the reference list.

Angela La Dow 

 

Manage Discussion Entry 

The name of the condition is Neonatal Abstinence Syndrome (NAS). The baby will be born with opioids on board and will require opioids or partial opioid receptor agonists to help the baby through withdrawl and detox. This process can be started while in utero with the mother in medication assisted treatment (MAT). The idea behind MAT is to use opioid agonists that do not fully cover the opioid receptors thereby reducing the euphoria of the full opioid (morphine, hydrocodone, fentanyl, oxycodone, & heroin). There are three treatment modalities for MAT; methadone, buprenorphine or the combo buprenorphine/naltrexone (Suboxone), and naltrexone itself (SAMHSA, 2018

 (Links to an external site.)

Links to an external site.

). Buprenorphine in combination with naltrexone completely blocks the full receptor so the effects can not be overcome by more opioids (to a certain extent) and reduces cravings. Once a patient is in MAT and dosed appropriately with a Suboxone dose that is the smallest dose to keep withdrawl away visits can be extended out if they are working therapy and group therapies such as NA and AA the psychosocial aspect of addiction. When a pregnant women starts MAT the amount of medication that crosses the placenta is the same as the mother’s and the fetus can start to slowly and safely reduce their exposure to full opioids (McQueen and Oikonen, 2016

 (Links to an external site.)

Links to an external site.

). A patient has to be off full opioids for at least 3 days before starting MAT with Suboxone. They are given Imodium, gabapentin, and clonidine to help reduce the withdrawl symptoms. If they are not they will go into full withdrawl with the initiating dose due to the naltrexone. 

Risks for the baby are low birth weight, STI infections, potential abuse and neglect, and preterm birth (McQueen & Oikonen, 2016). Opioid withdrawl for infants is more serious that opioid withdrawl for adults due to the seizures and other neurologic symptoms it can cause. Depending the type of opioid and the amount taken by the mother the severity of withdrawl will be different for each infant. There will be tremors, diarrhea, irritability, tachycardia and tachypnea, poor feeding, and possibly seizures (McQueen and Oikonen, 2016). Long-term effects of NAS are not well studied but it has been found that there can be some behavioral problems and mental health issues with these children as well as abuse and neglect by the parents (McQueen and Oikonen, 2016). 

There is a misconception that a women will automatically be placed in jail if the are using opioids while pregnant once they give birth so they do not seek prenatal care and sometimes will wait until they are in labor to be seen. There was on NAS infant in the hospital I work at who was born to the girlfriend of a MAT patient we were seeing. She left the hospital AMA because she did not tell anyone she was a heroin addict and started withdrawl. She could have been treated appropriately in the hospital and reduced her risk of hemorrhage and death and stayed with her baby. The goal for these women is to get them to bond with the baby, be able to manage their care in their home, and find supports for them over the long term (McQueen and Oikonen, 2016). 

My last preceptor became certified in addiction treatment with Suboxone so I got the opportunity to work with this population and see first hand the initiation of treatment, pride in getting clean, pride in staying clean, and the disappointment of relapse. There are not a lot of providers that are certified to do this treatment and they are only allowed a certain amount of patients per provider. The certifying body that maintains it just opened certification to NPs and PAs to manage patients. Generally recreational drug use and alcohol abuse escalates to heroin use. I saw at least four patients that started with legit prescriptions for opioids and progressed to heroin use. The others started with other recreational drug use and alcohol abuse. My last preceptor stated to me that if a pregnant women seeks MAT and is on it while in labor there are better outcomes for the baby and the mother and child protective services may be willing to work with her.

References

McQueen, K., & Oikonen, J. (2016). Neonatal Abstinence Syndrome. Retrieved from https://www.nejm.org/doi/full/10.1056/NEJMra1600879 

 (Links to an external site.)

Links to an external site.

SAMHSA. (2018). Medication assisted treatment. Retrieved from https://www.samhsa.gov/medication-assisted-treatment

 (Links to an external site.)

Links to an external site.