OUTLINE REPRODUCTION Women's Health Evolving area of health care Role of the nurse Emphasis on health promotion Significant hormones and hormonal changes Estrogens Progesterone Androgens Follicle stimulating hormone (FSH) and luteinizing hormone (LH) Perimenopause and menopause Health History and Sexual Assessment Menstrual history and history of pregnancies History of exposure to medications Pain with menses or intercourse Vaginal discharge, odor, or itching Urinary and bowel function Sexual history, including sexual or physical abuse History of STDs, surgeries or procedures Chronic illness or disabilities which affect health/self-care Family and genetic history Sexual Assessment Include subjective and objective data. Purpose obtain information to determine woman's sexuality sexual practices promote sexual health. Move from less sensitive areas of general health history/assessment to more sensitive areas. Ask for permission to discuss these issues. Do not assume sexual preferences. Asking the patient to label herself as married, single, etc. may be interpreted as inappropriate; asking about current meaningful relationships may be less offensive. PLISST model. Domestic Violence Broad term that includes child abuse, elder abuse, and the abuse of women and men Abuse can be: Emotional Physical Sexual Economic Asking about abuse is part of a comprehensive assessment Reporting abuse and guidelines Diagnostic Examinations and Tests Pelvic examination Pap smear
Colposcopy and cervical biopsy Cyrotherapy and laser therapy Cone biopsy and loop electrosurgical excision (LEEP) Endometrial biopsy Dilation and Curettage (D&C) Laparoscopy (pelvic peritoneoscopy) and hysteroscopy Menstrual Disorders Premenstrual syndrome (PMS) Dysmenorrhea Amenorrhea Abnormal uterine bleeding Menorrhagia Metrorrhagia Postmenopausal bleeding Nursing Care of the Patient with Premenstrual Syndrome (PMS) Assessment: health history, nutritional history, recording of symptoms potential for violence, suicide or uncontrollable behavior refer appropriately Identification of patient goals: improved coping reduction of anxiety improved relationships Interventions and patient teaching Social support, counseling, and stress reduction Diet and exercise Medications Menopause Permanent physiologic cessation of menses A/W declining ovarian function. Changes in menstruation Clinical manifestations Psychological considerations Medical management: HRT; risks and benefits Alternative therapy for hot flashes Nursing Teaching for the Patient Approaching Menopause View as natural life change a new phase with potential for growth and new activities. Promote general good health including diet and exercise. Fatigue and stress may worsen hot flashes. Nursing Teaching for the Patient Approaching Menopause Nutrition: decrease fat and calories Increase calcium whole grains Fiber
Fruit and vegetables. Calcium and vitamin D supplementation may be helpful. Address sexual activity and prevention or management of common problems. Contraception Each year more than half of all pregnancies are unintended. Nurses assist by providing women with information support women in making contraceptive choices Methods of Contraception Abstinence and natural methods Sterilization Tubal ligation Vasectomy Intrauterine device (IUD) Hormonal contraception Mechanical barriers Hormonal Contraception Benefits and risks Adverse reactions Contraindications Hormone types Estrogen and progestin Progestin only Patient education related to hormonal contraceptives Combination Oral contraceptives Vaginal Ring Transdermal patch Progestin Only Oral contraceptives Injection "Plan B" Levonorgesterol releasing intrauterine system Barrier Methods Diaphragm Cervical cap Contraceptive sponge Female and male condoms Assess for latex allergy Spermicidal: nonoxynol-9 and octoxynol Emergency Contraception Hormonal methods Plan B: progestin Dose of oral contraceptive (levonorgestrel and ethinyl estradiol) given and repeated in 12 hours Postcoital IUD insertion
Timing of emergency contraception Nursing support, teaching, and counseling Abortion Spontaneous abortion Habitual abortion Medical management Nursing support of the patient Grief process and dysfunctional grief Elective Abortion Pre-abortion counseling Pelvic examination and laboratory tests Use of RhoGAM for Rh-negative patient Types of elective abortions Patient teaching, including instruction for follow-up care and information on contraception Infertility A couple's inability to achieve a pregnancy after 1 year of unprotected intercourse. Primary infertility refers to couple who have never had a child. Secondary infertility means at least one conception has occurred but the couple cannot achieve a pregnancy. Pathophysiology of Infertility Ovarian and ovulation factors Tubal factors Uterine factors Semen factors Other male factors Management of Infertility Pharmacologic therapy Potential for multiple pregnancies Ovarian hyper-stimulation syndrome (OHSS) Artificial insemination In vitro fertilization Other technologies Ectopic Pregnancy A leading cause of pregnancy-related death in the first trimester Causes include Salpingitis peritubal adhesions structural abnormalities of the fallopian tube previous ectopic pregnancy previous tubal surgery tumors IUD progestin (only contraception) pelvic inflammatory disease (PID) Clinical manifestations:
Delay in menses Slight bleeding Vague soreness or sharp colicky pain, GI symptoms, dizziness, light-headedness With tube rupture: agonizing pain Dizziness faintness, N/V, progression to shock Later: generalized abdominal that radiates to shoulder
Note: Should be educated about early treatment and seek care if a period does not seem normal if pain with menses if pain and a suspected pregnancy Fatal hemorrhage may occur with ruptured ectopic pregnancy if treatment is delayed One ectopic pregnancy increases risk for recurrent ectopic pregnancy requires teaching regarding early signs and symptoms Nursing Process: The Care of the Patient with Ectopic Pregnancies--Diagnoses Acute pain Anticipatory grieving Deficient knowledge Collaborative Problems/Potential Complications Hemorrhage Hemorrhagic shock Nursing Process: The Care of the Patient with Ectopic Pregnancies--Planning Major goals include relief of pain acceptance and resolution of grief / pregnancy loss increased knowledge about ectopic pregnancy its treatment, outcome, and absence of complications Interventions Supporting of the grief process Listen and provide support If appropriate, the partner should participate in the process Referral for counseling as needed Management of complications Continuous/frequent monitoring of VS, LOC, amount of bleeding, I&O, laboratory values Bed rest Chapter 47 Management of Patients With Female Reproductive Disorders Vulvovaginal Infections--Pathophysiology Common problem. Vagina normally protected by acid pH maintained partially by Lactobacillus acidophilus
Vaginal epithelium is responsive to estrogen induces glycogen formation breaks down into lactic acid decreased estrogen decreases acid production Perimenopause and Menopause decreased estrogen R/T vaginal and labial atrophy tissue is more susceptible to infection Vaginal Infections Candidiasis Gardnerella Trichomonas vaginalis Bartholinitis Cervicitis Atrophic vaginitis Risk Factors for Vulvovaginal Infections Premenarch/perimenopause/menopause/low estrogen levels Pregnancy/oral contraceptives Poor hygiene Tight garments and synthetic clothing Frequent douching Antibiotics Allergies Diabetes mellitus Intercourse with infected partner/oral genital contact/HIV Nursing Process: The Care of the Patient with a Vulvovaginal Infection--Assessment Examine as soon as possible after onset of symptoms. Instruct patient not to douche prior to assessment. History includes: Physical and chemical factors Psychogenic factors Medical conditions Use of medications Sexual activity/history Nursing Process: The Care of the Patient with a Vulvovaginal Infection--Diagnoses Discomfort Anxiety Risk for infection or spread of infection Deficient knowledge Nursing Process: The Care of the Patient with a Vulvovaginal Infection--Planning Major goals relief of discomfort reduction of anxiety prevention of reinfection prevention of infection of sexual partner acquisition of knowledge about self-care
prevention of infection Interventions Sitz baths help relieve discomfort Explanation of cause of symptoms and methods to help prevent infections help reduce anxiety Douching is usually avoided therapeutic douching may be prescribed to reduce odors remove excessive drainage Patient education Handwashing proper hygiene preventive strategies measures to reduce risk information regarding Medications self-examination Genital Viral Infections Human papillomavirus (HPV) The most common sexually transmitted disease among sexually active young people Vaccine Treatment of genital warts Associated with cervical dysplasia and cervical cancer. Need annual PAP smears Herpes type 2 infection (herpes genitalis) A recurrent lifelong viral infection STD also transmitted by contact even when the carrier is symptomatic Causes painful itching and burning herpetic lesions Treatment of HSV-2 No cure Antiviral agents acyclovir (Zovirax) valacyclovir (Valtrex), and famiciclovir (Famvir) can suppress symptoms Recurrences A/W stress, sunburn, dental work, inadequate rest, and inadequate nutrition R/F infants delivered vaginally to become infected; C-section Nursing Process: The Care of the Patient with Genital Herpes--Assessment Health history Pelvic Examination Assess for risk factors for STDs Nursing Process: The Care of the Patient with Genital Herpes--Diagnoses Acute pain Risk for infection Risk for spread of infection Anxiety Deficient knowledge
Nursing Process: The Care of the Patient with Genital Herpes--Planning Major goals relief of pain and discomfort control of infections and control of spread relief of anxiety knowledge and adherence to treatment regimen knowledge regarding implications for future Interventions Proper hygiene Clean, soft, loose, absorbent clothing Avoid ointments and powders Encourage fluid intake and good nutrition Measures related to discomfort with urination Instructions regarding medications Rest Measures to prevent reinfection and spread of infection Measures to reduce anxiety Malignant Disorders of the Female Reproductive Tract Cervical, uterine, vaginal, vulvar, and ovarian cancers Early disease may not have symptoms Signs and symptoms depend upon location and may include vaginal discharge, pain, bleeding and systemic symptoms (weight loss and anemia) Prevention, screening, and early detection are vital Treatment of Reproductive Malignancies Surgery, chemotherapy, radiation, or a combination of these. Treatment may be curative or palliative Care of the surgery patient is similar to care of patients with other abdominal surgeries Hysterectomy Surgical removal of the uterus to treat Cancer dysfunctional uterine bleeding Endometriosis nonmalignant growths persistent pain pelvic relaxation and prolapse previous injury to the uterus Total hysterectomy Radical hysterectomy Types of approaches Laparoscopic Vaginal Abdominal Nursing Process: The Care of the Patient Undergoing a Hysterectomy--Assessment History Physical and pelvic exam Psychosocial and emotional responses
Patient knowledge Nursing Process: The Care of the Patient Undergoing a Hysterectomy--Diagnoses Anxiety Disturbed body image Acute pain Deficient knowledge Collaborative Problems/Potential Complications Hemorrhage DVT Bladder dysfunction Nursing Process: The Care of the Patient Undergoing a Hysterectomy--Planning Major goals relief of anxiety acceptance of loss of the uterus absence of pain or discomfort increased knowledge of self-care requirements absence of complications Interventions Anxiety Allow patient to express feelings Explain physical preparations and procedures Provide emotional support Body image Listen and address concerns Provide appropriate reassurance, Address sexual issues Approach and evaluate each patient individually Cancer of the Vulva 4% of gynecologic cancers most often in postmenopausal women Encourage regular pelvic exams, Pap smears, and self-examination for early diagnosis Risk factors include smoking, HPV infection, HIV, immunosuppressant therapy Cancer of the Vulva Symptoms: Long-standing pruritis and soreness May present as a chronic dermatitis, or a lump, ulcer, or mass Bleeding, foul-smelling discharge, and pain are late signs Vulvectomy Treatment for vulvar cancer includes wide excision of the vulva May be done with lymph node dissection Additional therapy may include radiation and/or chemotherapy Preoperative preparation includes assessment of patient including factors that may have delayed seeking care health habits Lifestyle include psychological assessment and provide support
Postoperative care includes addressing issues anxiety of Pain impaired skin integrity sexual dysfunction change in body image potential complications Infection Sepsis DVT hemorrhage Chemotherapy Usually administered IV Specific care required to address the SE & complications of chemo agent SE: neutropenia, thromobocytopenia nephrotoxicity, neurotoxicity hair loss hypersensitivity reactions nausea and vomiting Paclitaxil (Taxol) Carboplatin (paraplatin) Liposomal therapy Radiation Therapy External radiation therapy Intraoperative radiation therapy Internal (intracavity irradiation) Care of the patient undergoing radiation therapy Nursing Considerations Related to Intracavity Radiation Therapy Foley catheter Absolute bed rest, positioning restrictions Diet: low residue Hygiene Monitoring of patient Side effects of therapy Emotional support of patient Address potential for isolation Safety (Intracavity Radiation) Follow specific precautions related to time, distance, and use of shielding Methods to monitor staff exposure (film badges) No pregnant caregivers, and no pregnant visitors or visitors under age 18 Teaching for family/others in contact with patient Monitor that device is not dislodged. If it is dislodged, do not touch the radioactive object and notify radiation safety Discharge survey
Chapter 48 Assessment and Management of Patients With Breast Disorders Breast Disorders Breast cancer is a major health problem In the U.S., > 215,000 women and 1450 men develop the breast cancer > 40,000 die of breast cancer annually Risk Factors for Breast Cancer Female gender Age Personal and family history including genetic mutations Hormonal factors Exposure to radiation History of benign breast disease Obesity High-fat diet (controversial) Alcohol intake Guidelines for Early Detection of Breast Cancer Women in 20s30s: clinical breast exam at east every 3 years, then preferably annually after age 40 Mammography annually beginning at age 40 Women @ risk may have earlier initial screening, shorter screening intervals, or additional screening procedures such as ultrasound or MRI Beginning in 20s, breast self-examination (BSE) Breast Self-Examination Provide instruction to women regarding BSE. Instructions should be provided to men if there is a family history of breast cancer. Encourage BSE but do not overemphasize. Instructional materials can be obtained from ACS and The National Cancer Institute. Teaching Breast Self-Exam Best performed days 57 after first day of menses or once monthly for postmenopausal women. Review the feel of normal breast tissue and ways or identify changes. Routine BSE will help patient become familiar with her own "normal abnormalities." Demonstrate the examination technique. Learners then should perform a BSE demonstration on themselves or a breast model. Part of the examination may be done in the shower with soapy hands to glide over the breast and focus on underlying tissue. Note the importance of including the area between the breast and underarm, and the underarm itself. Discuss reporting of any changes. Describe the goals, methods of instruction, and methods of evaluation for a teaching plan for BSE. List resources for information and materials. Breast Disorders Benign
Breast pain Cysts Fibroadenomas Benign proliferative breast disease Atypical hyperplasia Lobular carcinoma in situ Malignant--breast cancer Diagnostic Tests Mammography Galactography Ulrasonsography Magnetic resonance imaging (MRI) Biopsies Percutaneous: fine-needle aspiration, core biopsies Surgical biopsies: excision, incision, wire needle localization Surgical Management: Breast Cancer Breast conservation treatment Total mastectomy Modified radical mastectomy Sentinel node biopsy and axillary lymph node dissection Breast conservation treatment Total mastectomy Modified radical mastectomy Sentinel node biopsy and axillary lymph node dissection Breast reconstruction surgery Breast Reconstruction with Tissue Expander Refer to fig. 48-6 A and B Breast Reconstruction with TRAM Refer to fig. 48-7 A and B Breast Reconstruction: Latissimus Dorsi Flap Refer to fig. 48-8 A and B Nonsurgical Management of Breast Cancer Radiation therapy--external beam, brachytherapy Chemotherapy Hormonal therapy Estrogen and progesterone receptor assay Selective estrogen receptor modulators (SERMs)-- tamoxifen Aromatase inhibitors--anastrazole, letrozole, exemestane Targeted therapy Nursing Process: The Care of the Patient Undergoing Breast Cancer Surgery-- Assessment How is the patient responding to her diagnosis? What coping mechanisms does she find helpful? What psychological or emotional supports does she have and use? Is there a partner, family member, or friend available to assist in making treatment choices? What are her educational needs?
Is she experiencing any discomfort? Nursing Process: The Care of the Patient Undergoing Breast Cancer Surgery-- Preoperative Diagnoses Deficient knowledge Anxiety Fear Risk for ineffective coping Decisional conflict Nursing Process: The Care of the Patient Undergoing Breast Cancer Surgery-- Postoperative Diagnoses Pain Disturbed sensory perception Disturbed body image Self-care deficit Risk for sexual dysfunction Deficient knowledge Drain management Arm exercises Hand and arm care Collaborative Problems/Potential Complications Lymphedema Hematoma/seroma formation Infection Nursing Process: The Care of the Patient Undergoing Breast Cancer Surgery- Planning Major goals may include: Increased knowledge about the disease and its treatment Reduction of preoperative and postoperative fear, anxiety, and emotional stress Improvement of decision-making ability; improvement in coping skills Improvement in sexual function Absence of complications Preoperative Interventions Review and reinforce information on treatment options. Prepare patient regarding what to expect before, during, and after surgery. Inform patient regarding surgical drain, arm and shoulder mobility, and range-of-motion exercises. Maintain open communications. Provide patient with realistic expectations. Support coping. Involve or provide information for supportive services and resources. Support patient decisions. Postoperative Interventions Inform patient regarding common postoperative sensations Maintain privacy Bra with breast form Provide information Support coping and adjustment
Counseling and referral See Table 48-5 and Chart 48-6 Monitor for potential complications Hand and Arm Care Potential for lymphedema formation after ALND Patient education Prevention is vital; follow guidelines for the rest of life No blood pressure, injections, or blood draws in the affected arm Perform exercises 3X a day for 20 minutes to increase circulation and muscle strength. Prevents stiffness and contractures, and restores ROM A mild analgesic or a warm shower may be helpful prior to exercise. Initial limitation of lifting (over 510 pounds) and activity Drainage Management May need home care referral to assist with drain management Drains usually removed when less than 30 mL drainage in a 24-hour period; usually 7 to 10 days. Drain site and incision care Chapter 49 Assessment and Management of Problems Related to Male Reproductive Processes Male Reproductive System Includes conditions that affect both reproduction and sexuality and urinary elimination Patient may experience anxiety and embarrassment Sensitivity to cultural and emotional issues related to sexuality and the genitals to accomplish effective assessment and communication Provide for privacy and education Assessment Urinary function and symptoms Sexual function and manifestations of sexual dysfunction Symptoms related to urinary obstruction Increased urinary frequency Decreased force of stream "Double" or "triple" voiding Nocturia, dysuria, hematuria, hematospermia Medications, drug, and alcohol use Presence of conditions that may affect sexual function (diabetes, cardiac disease, multiple sclerosis) PLISSIT Model of sexual assessment and intervention Permission Limited Information Specific Suggestions Intensive Therapy Physical Assessment
Digital rectal exam Testicular exam Diagnostic Tests Prostate specific antigen (PSA) Ultrasonography Prostate fluid or tissue analysis Tests of male sexual function Disorders of Male Sexual Function Erectile dysfunction Psychogenic and organic causes Organic causes include vascular, endocrine, hematological, and neurologic disorders, trauma, alcohol, medications, and drug abuse Medications associated with erectile dysfunction Ejaculation problems Premature ejaculation Retrograde ejaculation Medical Management Pharmacologic therapy Oral medications--sildenafil (Viagra) Side effects include headache, flushing, dyspepsia Caution with retinopathy Contraindicated with nitrate use Injected vasoactive agents Complications include priapism (persistent abnormal erection) Urethral suppository Penile implants Negative pressure devices Conditions of the Prostate Prostatitis--inflammation caused by an infectious agent Treatment includes appropriate anti-infective agents and measures to alleviate pain and spasm Benign prostatic hyperplasia (BPH, enlarged prostate) Half of men over age 50 and 80% of men over age 80 Manifestations are those of urinary obstruction, urinary retention, and urinary tract infections Treatment Pharmacologic--alpha-adrenergic blockers, alpha- adrenergic antagonists, antiandrogen agents Catherization if unable to void Prostate surgery Prostate Cancer Second most common cancer and the second most common cause of cancer death in men Risk factors include increasing age, familial predisposition, and African-American race Manifestations Early disease has few/no symptoms Symptoms of urinary obstruction, blood in urine or semen, painful ejaculation
Symptoms of metastasis may be the first manifestations Early diagnosis is vital; health screening Treatment may include Prostatectomy radiation therapy hormonal therapy chemotherapy Nursing Process: The Care of the Patient Undergoing Prostatectomy--Assessment Assess how the underlying disorder (BPH or prostate cancer) has affected the patient's lifestyle Urinary and sexual function Health history Nutritional status Activity level and abilities Nursing Process: The Care of the Patient Undergoing Prostatectomy-- Diagnoses Anxiety Acute pain preoperatively Acute pain postoperatively Deficient knowledge Collaborative Problems/Potential Complications Hemorrhage and shock Infection DVT Catheter obstruction Sexual dysfunction Nursing Process: The Care of the Patient Undergoing Prostatectomy--Planning Major goals preoperatively adequate preparation reduction of anxiety/pain Major goals postoperatively maintenance of fluid volume balance relief of pain and discomfort ability to perform self-care activities absence of complications Relief of Pain Monitor urinary drainage and keep catheter patent Assessment of pain Bladder spasms cause feelings of pressure and fullness urgency to void bleeding from the urethra around the catheter Medication and warm compresses or sitz baths to relieve spasms Administer analgesics and antispasmodics as needed Encourage patient to walk, but to avoid sitting for prolonged periods. Prevent constipation Irrigate catheter as prescribed Interventions
Reduction of anxiety Sensitivity R/T embarrassing/culturally charged issues Establish a professional, trusting relationship Provide privacy Allow patient to verbalize concerns Provide and reinforce information Provide patient teaching explanations of anatomy and function diagnostic tests and surgery surgical experience Rehabilitation and Home Care Patient and family teaching for home care Care of urinary drainage devices Recognition and prevention of complications Regain bladder continence Regaining control is a gradual process dribbling may continue for up to 1 year depending upon type of surgery Perineal exercises Avoidance of straining, heavy lifting, long car trips (68 weeks) Diet: encourage fluids and avoid coffee, alcohol, and spicy foods Assessment and referral of sexual issues Testicular Cancer Most common cancer in men ages 1540 Highly treatable and curable Risk factors: undescended testicles, positive family history, cancer of one testicle, Caucasian-American race Manifestations: painless lump or mass in the testes Early diagnosis: monthly testicular self-exam (TSE) and annual testicular exam Treatment: Orchidectomy retroperitoneal lymph node dissection (open or laparoscopic) radiation therapy chemotherapy Nursing Management Assessment of physical and psychological status Support of coping Address issues of body image and sexuality Encourage a positive attitude Patient teaching TSE and follow-up care Conditions Affecting the Penis Hypospadias and epispadias Meatus opening on the dorsal or ventral penile surface Phimosis Penile cancer Bowen's disease
SCC in situ with high potential for lateral spread Caused by sun exposure, arsenic, HPV, immunosuppression etc
Priapism Peyronie's disease Urethral stricture Circumcision