Chapter 46 Assessment and Management of Female Physiologic Processes

1. Chapter 46 Assessment and Management of Female Physiologic Processes

2. Women’s Health • Evolving area of health care • Role of the nurse • Emphasis on health promotion

3. Review of Anatomy and Function • Function of the female reproductive system • Ovulation and the menstrual cycle • Significant hormones and hormonal changes • Estrogens • Progesterone • Androgens • Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) • Perimenopause and menopause

4. External Female Genitalia

5. Internal Female Reproductive Structures

6. Menstrual Cycle

7. 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 that affect health/self-care • Family and genetic history

8. Sexual Assessment • Include subjective and objective data. • Purpose is to obtain information to picture a woman’s sexuality and sexual practices to promote sexual health. • May 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

9. Domestic Violence • A 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.See Chart 46-3 • Reporting abuse and guidelinesSee Chart 46-2

10. Diagnostic Examinations and Tests • Pelvic examination • Pap smear • Colposcopy and cervical biopsy • Cryotherapy and laser therapy • Cone biopsy and loop electrosurgical excision (LEEP) • Endometrial biopsy • Dilation and curettage • Laparoscopy (pelvic peritoneoscopy) and hysteroscopy

11. Speculum Examination of the Vagina and Cervix

12. Bimanual Examination of the Pelvis

13. Use of Ayre Spatula to Obtain Cervical Secretions for Cytology

14. Laparoscopy

15. Menstrual Disorders • Premenstrual syndrome • Dysmenorrhea • Amenorrhea • Abnormal uterine bleeding • Menorrhagia • Metrorrhagia • Postmenopausal bleeding

16. Nursing Care of the Patient with Premenopausal Syndrome (PMS) • Assessment: health history, nutritional history, recording of symptoms • Assess for potential for violence, suicide or uncontrollable behavior, and 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

17. Menopause • Permanent physiologic cessation of menses associated with declining ovarian function • Changes in menstruation • Clinical manifestations • Psychological considerations • Medical management: HRT; risks and benefits • Alternative therapy for hot flashes

18. 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. • Note that fatigue and stress may worsen hot flashes. • Nutrition: decrease fat and calories and 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. • See Chart 46-8

19. Contraception • Each year more than half of all pregnancies are unintended. • Nurses can assist by providing women with information and support women in making contraceptive choices.

20. Methods of Contraception • Abstinence and natural methods • Sterilization • Tubal ligation • Vasectomy • Intrauterine device (IUD) • Hormonal contraception • Mechanical barriers

21. Hormonal Contraception • Benefits and risks • Adverse reactions • Contraindications • Hormone types • Estrogen and progestin • Progestin only • Patient education related to hormonal contraceptives

22. Oral pills Vaginal ring Transdermal patch Oral pills or mini-pills “Plan B” Injection Levonorgestrel- releasing intrauterine system Combination Progestin Only

23. Barrier Methods • Diaphragm • Cervical cap • Contraceptive sponge • Female and male condoms • Note: assess for latex allergy! Spermicides: nonoxynol-9 and octoxynol

24. Female Condom

25. Emergency Contraception • Hormonal methods • Plan B: progestin • Dose of oral contraceptive (i.e., levonorgestrel and ethinyl estradiol) given and repeated in 12 hours • Postcoital IUD insertion • Timing of emergency contraception • Nursing support, teaching, and counseling

26. Abortion • Spontaneous abortion • Habitual abortion • Medical management • Nursing support of the patient • Grief process and dysfunctional grief

27. Elective Abortion • Pre-abortion counseling • Pelvic examination and laboratory tests • Use of RhoGAM for Rh-negative patient • Types of elective abortions • Patient teaching, including instructions for follow-up care and information on contraception

28. Infertility • A couple’s inability to achieve a pregnancy after 1 year of unprotected intercourse • Primary infertility refers to a couple who have never had a child. • Secondary infertility means at least one conception has occurred but the couple cannot achieve a pregnancy.

29. Pathophysiology of Infertility • Ovarian and ovulation factors • Tubal factors • Uterine factors • Semen factors • Other male factors

30. Management of Infertility • Pharmacologic therapySee Chart 46-16 • Potential for multiple pregnancies • Ovarian hyperstimulation syndrome (OHSS) • Artificial insemination • In vitro fertilization • Other technologies

31. 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, and pelvic inflammatory disease (PID) • Clinical manifestations • Delay in menses, slight bleeding, vague soreness or sharp colicky pain, GI symptoms, dizziness, lightheadedness • With tube rupture: agonizing pain, dizziness, faintness, N/V, progression to shock • Later: generalized abdominal pain that radiates to shoulder

32. Sites of Ectopic Pregnancy

33. Note: • All women need to be educated about early treatment and seek care if a period does not seem normal or if they have pain or pain and a suspected pregnancy. • Fatal hemorrhage may occur with ruptured ectopic pregnancy if treatment is delayed. • Women who have had an ectopic pregnancy are at increased risk for recurrent ectopic pregnancy and require teaching regarding early signs and symptoms.

34. Nursing Process: The Care of the Patient with Ectopic Pregnancies- Diagnoses • Acute pain • Anticipatory grieving • Deficient knowledge

35. Collaborative Problems/Potential Complications • Hemorrhage • Hemorrhagic shock

36. Nursing Process: Care of the Patient with Ectopic Pregnancy: Planning • Major goals include relief of pain, acceptance and resolution of grief and pregnancy loss, increased knowledge about ectopic pregnancy and its treatment and outcome, and absence of complications.

37. Interventions • Supporting 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