Reproductive System

1. Reproductive System NUR 302 Unit II

2. Sexually Transmitted Diseases • Gonorrhea & syphilis reportable to health dept, genital herpes & warts not • Often STDs coexist • 30% gonorrhea - resistant strains • 25-40% cases– teenagers, young adults • Incidence of syphilis declining • Chlamydia trachomatis- most prevalent

3. Contributing Factors to STDs • Earlier maturity, increased longevity • Sexual freedom, media, changes in women, marriage, religion, family • Drug abuse correlates with STDs • Methods of contraception

4. Gonorrhea • Niesseria gonorrhoeae – in male urethra, cervix, rectum, oropharynx • Spread by direct physical contact • Killed by drying, heating, washing with antiseptic soln • Incubation- 3-4 days • Inflam. response->fibrous tissue, adhesions, scarring

5. Clinical Manifestations • Men: urethitis, dysuria, purulent disch. • Women: no s/s, vaginal discharge, dysuria, freq urination, menstr. changes, red, swollen, purulent urethral drainage, cervix->abscess, & spreads • Anorectal – no s/s, proctitis, pharyngitis

6. Complications & Diagnosis • Men: prostatitis, ureth strictures, sterility • Women: PID, Bartholin abscess, ectopic preg, infertility, DGI- skin lesions, fever, arthritis • Opthalmia neonatorum • Dx: culture of drainage, gram stain, history, rectal culture, DNA probe technique & poymerase chain reaction

7. Drug Therapy • Penicillin • Cipro • Rocephin • Cefixine • Vibramycin • Treat all sexual contacts of pts • Abstain from alcohol & sex. intercourse

8. Syphilis • Trepomema pallidium • Destroyed by heating, drying, washing • Enters via small breaks in skin or mucous membrane, needle sharing, contact with infected lesions, congenital • Incubation: 10-90 days (3 weeks) • Capillary dilation & swelling, proliferation of endothelium, new blood vessels form, scar tissue forms when healing

9. Clinical Manifestations • Primary stage: chancres • Secondary stage: systemic, spread to all organs, rash, alopecia, adenopathy • Latent period: no s/s, immune system suppresses infection, + antibodies • Late (Tertiary): gummas, ht failure, aneurysms, paresis, psychosis, mental deterioration, ataxia, jt damage

10. Complications & Diagnosis • Gummas->bone, liver, skin damage • Cardiovascular – ruptured aneurysms, scarring of aortic valve • Neurosyphilis – sudden pain anywhere in body, mental changes, ataxia, vision loss, prob walking • Dx: H&P, dark field microscopy of lesion scrapings, VDRL, RPR

11. Drug Therapy • Treatment can not reverse damage • IV Penicillin • Doxycycline, tetracycline, erythromycin • Treat maternal syphilis before week 18; treatment in 2nd half preg-> premature labor • Neurosyphilis – management also depends on neuro s/s

12. Chlamydial Infections: Urogenic Infections • Chlamydia trachomatis, many strains • Urethitis & cervicitis, assoc with gonococcal infections, incub:1-3 weeks • S/S: urethitis, epididymitis, proctitis, cervicitis, freq urination, barthinitis, PID, perihepatitis • Complic: infertility, Reiter’s disease, PID, ectopic preg

13. Diagnosis & Care • Dx: exclude gonorrhea – smear of ureth discharge(men), first catch urine, culture, nonculture tests • Drugs: Vibramycin, Zithromax, Floxin • If pregnant: Erythromycin, Amoxicillin • Follow up care, treat partners, use condoms, if s/s persist seek care

14. Lymphogramuloma Vernereum • Stain of C. trachomatis, chronic STD • Africa, India, SE Asia, Caribbean, S America • Enter skin & m membrane via abrasion, spread via bld & enters CNS • Penile, anal, vulvar infection, ing & fem lymph enlargement,necrosis, abscesses, fibrosis, lymph node dysfunction, complic – fistulas • Rx: pt & partner, tetracycline

15. Genital HerpesHerpes Simplex Virus (HSV) • HSV-1: infection above waist • HSV-2: genital tract & perineum • Dormant on sensory nerve ganglion • Recurrences: HSV moves down nerve axion to skin or mucous membrane • Virus enters thru mucous membrane or breaks in skin. • Viral shedding in absence of lesion • Incubation: 1-45 days, (ave. 6)

16. Clinical Manifestations • Initial burning tingling • Vesicular lesion on penis, scrotum, vulva, perineum, perianal, vagina, cervix • Rupture, ulcer, crust, epithelialization • Pain, fever, headache, malaise, myalgia, lymphadenopathy • Dysuria, retention, vag discharge • Lesions last 17-20 days, new dev 6wks

17. Clinical Manifestations: Transmission of HSV • Transmission with or without lesion & if asymptomatic • Barrier contraception decreases transmission • Avoid sex when lesion present • Antiviral agents reduce but not prevent viral shedding

18. Complications & Diagnosis • CNS- aseptic meningitis, lower neuron damage • Virus spread to fingers, lips, breast • HSV & pregnancy – hi risk transmission to infant, C- Section • Dx: s/s, history, culture

19. Care & Drug Therapy • Wear loose cotton underwear, keep lesions dry, hairdryer, good hygiene, sitz bath, pour water when urinating • Health promotion: use condoms, abstain from sex if have lesions • Pain: lidocaine, codeine, ASA • Zovirax, Valtrex, Famvir

20. Condylomata Acuminata:Genital Warts • Human papilloma virus (HPV), highly contagious, incubation 1-6 mo • Single, multiple growths, grow rapidly during preg, may transmit to baby • Link with cervical & vulvar cancer & in men anorectal & penile cancer • Dx: by appearance of lesion, Virapap • Tx: remove symptomatic warts

21. Nursing Management of STDs • Assessment • Health promotion: “safe sex”, teaching pt with STD, screening cervical cancer & STDs, case finding, community educ • Acute care: psychol support, explain tx & s/e, follow up rx, teach hygiene, abstinence from sex

22. Breast Disorders: Health Promotion Practices • Risk factors for breast cancer • Monthly breast self exam over age 18 • Physical exam q3yrs age 20 – 40 & over 40 q year • Mammography • Follow up care

23. Assessment of Breast Disorders • Males: 1% breast cancer, gynacomastia • Breast cancer mostly post menopause • Family history significant • Assess: pain, nipple discharge, lump size, location, rate of growth, correlation with menstrual cycle, consistency, mobility, shape, single or multiple ducts, one or both breasts

24. Diagnostic Studies • Mammography • Biopsy – only definitive dx for cancer • Fine needle aspiration • Open surgical biopsy • Stereotactic core biopsy

25. Benign Breast Problems • Mastalgia – Pain, coincides with menstrual cycle • Mastitis – inflammation, lactating women, staph via cracked nipple, fever, red, warm, tender, continue breast feeding , use shield or express milk • Lactational breast abscess – no response to antibiotics, I&D, C&S, express & discard milk

26. Fibrocystic Changes • Benign, excess fibrous tissue, cyst, pinches nerve endings->pain • No risk for cancer, nodules in bilateral upper outer quadrant • Common age 35 – 50, response to estrogen & progesterone • Lump well rounded, delineated, movable, enlarge with menstrual cycle • DX: mammogram, ultrasound

27. Fibrocystic Changes • Aspirate or biopsy esp if hi risk for breast cancer • Teach breast self exam, follow up exams thu life, report new lumps or changes • Wear good bra, lo salt diet, decrease chocolate & caffeine, diuretic, hormones, vit E, Danazol, decr stress

28. Fibroadenoma • Benign, cause of breast tumor in women under 25, African Americans • Increased estrogen sensitivity • Small, painless, round, movable, soft or rubbery, slow growth, no relation to cycle but increase if pregnant • Dx: biopsy, tx- excision • Teach self breast exam, follow up

29. Benign Breast Problems • Nipple discharge – milky,serous, bloody, green, brown • Intraductal papilloma – warts in mammary ducts • Ductal ectasia– peri & postmenopausal, sticky, multicolored discharge, burning, itchy, bloody discharge, nipple retraction, abscess

30. Gynecomastia • Male enlargement of one or both breasts, benign • Imbal of androgen & estrogen, can be s/s of other problem • Pubertal gynecomastia – age 13-17,disappears 4-6 months • Senescent gynecomastia

31. Breast Cancer

32. Risk Factors • Female, age 50 or over • Family history • BRCA-1, BRCA-2 gene mutations • H/O breast, colon, endometrial, ovarian cancer • Early menarche • Full term pregnancy after age 30, nulliparity • Benign breast disease with atypical epithelial hyperplasia • Obesity after menopause • Exposure to ionizing radiation

33. Clinical Manifestations • Lump • commonly found in upper outer quadrant • hard, irreg shape, not delineated • fixed, nontender • Dimpling of skin • Nipple discharge, retracted nipple • Orange peel skin

34. Diagnostic Studies • Mammography • Ultrasound • Biopsy • Fine needle biopsy • Stereotactic core biopsy • Axillary lymph node status – 4 or more + nodes ->greatest risk of recurrence • Lymphatic mapping & sentinel lymph node dissection

35. Types of Breast Cancer • Ductal cancer • Lobular cancer • Insitu vs invasive • Paget’s disease – malignant persistent lesion of areola & nipple • Inflammatory breast cancer – rare, most malignant, red, warm, orange peel or hives look

36. Prognosis Variables • Tumor size & differentiation • Axillary node involvement • DNA content analysis • Genetic marker HER-2/neu (c-erb-B2 or neu) • Estrogen & progesterone receptor status • Cell proliferation indices

37. Collaborative Care • TNM Classification: size of tumor, nodal involvement, metastasis -> staging 0-IV • Breast conservation surg (lumpectomy) with radiation • Modified radical mastectomy with/out reconstruction • Axillary node dissection • Follow up care rest of life- reoccurrence at surg site or opposite breast

38. Recurrence & Metastasis • Local – skin • Regional – lymph nodes • Distant metastasis • Skeletal • Spinal cord • Brain • Pulmonary • Liver • Bone marrow

39. Radiation Therapy • Primary radiation therapy – after tumor removed, external beam, s/e esophagitis, tracheitis, fatigue, skin, breast edema • Radiation as adjunct to therapy- pre-op • Palliative – rx of metastasis to bone, brain, chest, soft tissue, relieves pain, decrease reoccurrences

40. Chemotherapy • Very responsive to chemo • Combinations of drugs- effects on cell growth & division at different stages • Cytoxin, 5FU, Vincristine & Prednisone • Andriamycin, 5FU, Taxol, Taxotere • S/E: GI tract, bone marrow, hair

41. Hormonal Therapy • Estrogen can promote growth of breast cancer • Oopherectomy, adrenalectomy, hypophysectomy • Determine estrogen & progesterone receptor status of tumor • Tumor regression with hormone manipulation • Tamoxifen, Toremifene, Arimidex

42. Nursing Care: Breast Cancer • Psychol support during dx & tx • Provide info on tx choices, diag tests • Pre-op teaching • Help restore arm function on affected side- elevate, finger/arm exercises • Lymphedema- arm never dependent, no BP, bld work, or injections • Pain, fear, body image disturbance

43. Nursing Care: Breast Cancer • Reach to Recovery Program • Accurate answers to questions • Teach follow up care • Report fever, inflammation, redness, swelling, weakness, new pain, SOB • Prosthesis, breast reconstruction • Implications on sexual identity • Depression

44. Mammoplasty • Surgical change in breast size or shape • Breast augmentation – saline implants • Breast reduction • Post-op – drains, observe s/s hemorrhage or infection, wear good supporting continuously for 2-3 weeks, no strenuous exercise

45. Ovarian Cancer • Risk factors: family history, hi fat diet, age, BRCA-1 gene mutation • Protective: mult preg, breast feeding, preg at early age • Asymptomatic early, pain, increase in abdomen, ascites, bowel & bladder prob • Dx: CA-125, yrly exam, ultrasound • Rx: total hysterectomy, chemo, radiation

46. Nursing Implementation • Health Promotion: routine screening, teach risks for cancer • Psychological support - grieving • Hysterectomy- vaginal or abdominal • Mod amt blding 1st 8 hrs, urinary retention, abd distention, menopause, thrombophlebitis • Discharge: no lifting, brisk walking, dancing, can swim, no menses, 4-6 wks no sex

47. Endometrial Cancer • Risk factor- unopposed estrogen, incr age, obesity, hi BP, DM • Adenocarcinoma common, grows slow, mets late, early dx & tx-> + prognosis • Mets to liver, lung, bone,brain • S/S: abnormal uterine bleeding • Dx: endometrial biopsy; tx total hysterectomy, radiation, progesterone, chemo

48. Cervical Cancer • Slow progression, repeated cervical injury; HPV with smoking • No s/s early, leukorrhea, intermenstral blding, anemia, wt loss, cachexia • Dx: Pap test, Schiller iodine test, biopsy, colposcopy • Rx: classII- 3-4mo follow up, class III> biopsy, conization; invasive- hysterectomy, radiation

49. Pelvic Inflam. Disease (PID) • Untreated cervicitis ascends; may involve fallopian tubes, ovaries, pelvic peritoneum • S/S: lower abdom pain, spotting, vag discharge, fever • Dx: s/s, pelvic exam • Complications: septic shock, Fitz-Hugh Curtis symdrome, abscess, peritonitis, emboli • Long term: ectopic preg, infertility, chr pain

50. PID: Collaborative & Nsg Care • Antibiotics, no sex 3 wks, BR- Semi Fowler’s position, fluids, exam partners, repeat exam 48-72 hrs, analgesics • Prevention- teach risk factors, early recog & tx cervicitis • Monitor pain, heating pad lower abd, sitz bath, teaching prevention- barrier methods, reason for BR, VS, monitor vaginal discharge