1. The Nurse’s Role in Women’s Health Care
Chapter 11
The Nurse’s Role in Women’s Health Care

2. Objectives Explain aspects of preventive health care for women.
Describe each menstrual disorder and its care.
Explain each gynecological infection in terms of cause, transmission, treatment, and care.
Describe the various methods of birth control, including side effects and contraindications for each method.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

3. Objectives (cont.)
Describe how to use natural family planning methods for contraception or infertility management.
Describe possible causes and treatment of infertility.
Explain the changes that occur during the perimenopausal period and after menopause.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

4. Objectives (cont.)
Explain the medical and nursing care of women who are nearing or have completed menopause.
Discuss the medical and nursing care of women with pelvic floor dysfunction or problems related to benign growths in the reproductive tract.
Describe the nursing care and treatment of a woman with leiomyoma.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

5. Goals of Healthy People 2020
Culturally competent communication key to empowering women to feel confident abut her ability to care for herself and her family
Increasing the number of women who engage in preventive health care, thereby reducing breast and cervical cancer, vertebral fractures, sexually transmitted infections
Achieving these goals requires preventive care, screening, and increased accessibility to health care
How can the health care system assist patients in meeting these goals?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

6. Preventive Health Care for Women
Teaching how to perform breast self-examination (BSE)
Mammography
Vulvar self-examination (VSE)
Pap test for all women 18 years or older (or whenever they become sexually active [whichever comes first])
Includes pelvic examination
Discuss the nurse’s role in teaching breast self-examination and vulvar self-examination.
What is the importance of Pap tests? NOTE: Toward the end of 2009, National Health Recommendations came out stating a woman does not need to start having Pap tests until age 21 and may not need to have them yearly. This is highly controversial and remains an unresolved issue at the time of publication.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

7. Menstrual Disorders Common nursing roles include
Explaining any recommended treatments
Caring for the woman before and after procedures
Provide emotional support
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

8. Amenorrhea The absence of menstruation
Normal before menarche, during pregnancy, and after menopause
Primary
Secondary
Treatment depends on cause identified
What are the differences between primary and secondary amenorrhea?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

9. Abnormal Uterine Bleeding
Three types
Too frequent
Too long in duration
Excessive in amount
Common causes
Pregnancy complications
Lesions of the vagina, cervix, or uterus
Breakthrough bleeding when on contraceptives
Endocrine disorders
Failure to ovulate
Describe the three types of uterine bleeding.
What are typical endocrine disorders that could cause abnormal uterine bleeding?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

10. Menstrual Cycle Pain
Mittelschmerz is pain that many women experience around ovulation, near the middle of their menstrual cycle
Dysmenorrhea, painful menses or cramps
Primary—no evidence of pelvic abnormality
Secondary—a pathologic condition is identified
Vasopressins and prostaglandins from the endometrium contribute
Potent stimulants of painful uterine contractions
What are some methods to ease these menstrual cycle pains?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

11. Endometriosis
The presence of tissue that resembles the endometrium outside of the uterus
Can cause pain, pressure, and inflammation
More constant than spasmodic
Can cause dyspareunia (painful sexual intercourse)
Discuss treatment for endometriosis.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

12. Premenstrual Dysphoric Disorder (PMDD)
Formerly called premenstrual syndrome
Associated with abnormal serotonin response to normal changes in estrogen levels
Symptoms occur between ovulation and the onset of menstruation
Are not present the week after menstruation has occurred
What are typical signs and symptoms of PMDD?
Discuss patient education to minimize the effects of PMDD.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

13. Symptoms/Diagnosis of PMDD
Five or more must occur regularly
Depressed mood
Anxiety, tension, feeling “on edge”
Increased sensitivity to rejection
Irritability
Decreased interest in usual activities
Difficulty in concentrating
Lethargy
Change in appetite
Change in sleep habits
Feeling overwhelmed
Physical symptoms; i.e., breast tenderness, bloating, weight gain, headaches
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

14. Gynecological Infections
Nurse’s role
Educating women concerning vaginal health
Prevention of STIs
Identifying high-risk behaviors
Safe sex practices
Reducing number of sexual partners
Avoiding exchange of bodily fluids
Provide nonjudgmental, sensitive counseling
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

15. Preventing Vaginal Infections
Teach the woman to
Wear cotton underwear
Avoid tight nylon or Spandex pants
Wipe front to back after toileting
Frequent hand hygiene
High-fiber, low-fat diet
Exercise
Avoid douching or using internal feminine hygiene products
Discuss the rationale for wearing cotton underwear and avoiding tight pants.
What is the rationale regarding a high-fiber, low-fat diet?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

16. Toxic Shock Syndrome (TSS)
Usually caused by strains of Staphylococcus aureus toxins that can produce shock, coagulation defects, and tissue damage if they enter the bloodstream
Usually results from the trapping of bacteria in the reproductive tract for a prolonged period of time
Use of high-absorbency tampons
Use of a diaphragm or cervical cap for contraception
Discuss the pathophysiology regarding Staphylococcus aureus and TSS.
How do you prevent TSS?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

17. Signs and Symptoms of TSS
Sudden spiking fever
Flu-like symptoms
Hypotension
Generalized rash that resembles a sunburn
Skin peeling from palms of hands and soles of feet after 1 to 2 weeks of the illness
Give an example of a patient presenting with signs and symptoms of TSS.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

18. Prevention of TSS Hand hygiene Change tampons at least every 4 hours
Do not use super-absorbent tampons
Use peripads rather than tampons when sleeping
Do not use diaphragm or cervical cap during the menstrual period
Remove diaphragm or cervical cap as recommended by the health care provider
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

19. Sexually Transmitted Infections
Infections that can be spread by sexual contact, although some have other modes of transmission
What are other modes of transmitting STIs?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

20. Types of Sexually Transmitted Infections
Fungal or bacterial
Candidiasis
Trichomoniasis
Bacterial vaginosis
Chlamydia trachomatis
Gonorrhea/GC
Syphilis
PID
Viral
Herpes simplex virus II (HSV-II)
Condylomata acuminata
Human papillomavirus (HPV)
Hepatitis B
HIV/AIDS
Discuss each STI listed and its mode of transmission.
How can the transmission of STIs be avoided?
Audience Response Question #1
What puts the patient at greatest risk for developing cervical cancer?
1. History of fibroid tumors
2. Repeated gonorrheal infections
3. History of endometriosis
4. History of human papillomavirus
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

21. Family Planning
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

22. The Nurse’s Role
Answering general questions concerning contraceptive methods
Explaining different methods available
Advantages
Disadvantages
Teaching correct use of contraceptive methods
What questions might a woman ask regarding contraceptive methods?
Give examples of proper and improper education regarding contraceptive methods.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

23. Factors that Influence Choice of Contraceptive Methods
Age
Health status
Religion or culture
Impact of unplanned pregnancy on the woman or family
Desire for future children
Frequency of sexual intercourse
Convenience and degree of spontaneity desired
Expense
Number of sexual partners
Give examples of situations in which age, religion, and convenience affect a woman’s contraceptive choices.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

24. Natural Family Planning
Also called fertility awareness
Involves learning to identify the signs and symptoms associated with ovulation
Acceptable to most religions
Requires no administration of medication or use of devices
Natural family planning is reversible
Failure rate of 20%
How can a woman determine when to abstain from sexual intercourse to prevent pregnancy?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

25. Types of Natural Family Planning
Basal body temperature
Cervical mucus
Calendar or rhythm method
Marquette method
Discuss each method and how it is utilized.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

26. Hormonal Contraception
Is another form of temporary birth control
Types
Monthly
Extended
Delayed menstruation
Implants
Injections
Transdermal patch
Vaginal ring
IUD
Prevents ovulation
Makes cervical mucus thick and resistant to sperm penetration
Makes uterine endometrium less hospitable if fertilized ovum arrives
Does not protect either partner from STIs, including HIV
Describe each type of temporary birth control method.
What safety measures need to be taken (e.g., blood tests)?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

27. ACHES—Warning Signs to Report when Taking Oral Contraceptives
Abdominal pain (severe)
Chest pain, dyspnea, bloody sputum
Headache (severe), weakness, or numbness of extremities
Eye problems
Severe leg pain or swelling, speech disturbance
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

28. Medications that Decrease Oral Contraceptive Effectiveness
Some antimicrobials, such as ampicillin and tetracycline
Anticonvulsants
Rifampin
Barbiturates
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

29. Barrier Contraceptives
Diaphragm
Cervical cap
Male condom
Female condom
Spermicides
Discuss and describe each barrier device.
What are the two types of female condoms?
Audience Response Question #2
A 16-year-old female comes to the family planning clinic for contraceptive advice. She says she wants to take “the pill.” Her vital signs are within normal limits. What assessment information is priority?
1. Exercise history
2. Nutritional information
3. Smoking history
4. Stress assessment
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

30. Emergency Contraception
The “morning after pill” is a method of preventing pregnancy
Must be taken no later than 72 hours after unprotected sexual intercourse and may need to be repeated 12 hours after the first pill
Depends on the type of pill purchased
In what situations would this type of contraception be used?
Discuss potential complications with this method.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

31. Unreliable Contraceptive Methods
Withdrawal
Douching
Breastfeeding
Providing 10 breast feedings in a 24-hour period can inhibit ovulation due to increased prolactin secretion
Why are these methods unreliable?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

32. Permanent Contraception
Male sterilization
Vasectomy
Female sterilization
Tubal ligation
Hysteroscopic sterilization
Discuss Figure 11-5 on page 266.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

33. Infertility Care
Infertility occurs when a couple who has regular unprotected sexual intercourse for 1 year cannot conceive
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

34. Social and Psychological Implications Related to Infertility
Assumption of fertility
Psychological reactions
Guilt
Isolation
Depression
Stress on the relationship
Cultural and religious considerations
Discuss the psychological reactions to infertility and how a nurse can provide emotional support to the patient.
What are some cultural and religious implications for couples who are experiencing infertility?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

35. Factors Affecting Fertility
Male
Abnormal
Sperm
Erections
Ejaculation
Seminal fluid
Female
Disorders of ovulation
Abnormalities of
Fallopian tubes
Uterus, cervix, or ovaries
Hormones
Discuss the pathophysiology regarding each factor.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

36. Factors Influencing Fertility
Coital frequency
Age
Cigarette smoking
Exercise, diet, and weight
Emotional factors
Medical problems
Drugs and chemicals
How do these factors affect fertility?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

37. Evaluation of Infertility
Male
Semen analysis
Endocrine test
Ultrasonography
Testicular biopsy
Female
Ultrasonography
Postcoital test
Endocrine test
Hysterosalpingogram
Endometrial biopsy
Hysteroscopy
What do endocrine tests evaluate for a male and for a female?
Discuss a postcoital test, how it is performed, and what the test results indicate.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

38. Therapy for Infertility
Medications
Surgical procedures
Therapeutic insemination
Surrogate parenting
Advanced reproductive techniques
IVF
GIFT
TET
ZIFT
Microsurgical techniques
Which medications and surgical procedures enhance fertility?
Discuss each reproductive technique.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

39. Infertility Therapy Outcomes Achievement of pregnancy to viability
Unsuccessful
Pregnancy loss after treatment
Legal and ethical issues
Surrogates
Parental rights
Cloning
Sale of frozen embryos
Nursing care related to infertility treatment
Supporting the couple
Teaching coping skills
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

40. Menopause
Cessation of menstrual periods for a 12-month period because of decreased estrogen production
Climacteric—change of life—is also known as the perimenopausal period (which is 2 to 8 years before menstruation ceases)
Pregnancy can still occur during the climacteric
How can a woman become pregnant during the climacteric?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

41. Physical Changes in Menopause
Usually caused by a decrease in estrogen
Changes in the menstrual cycle
Vasomotor instability, known as hot flashes
Decreased elasticity and moisture of the vagina
Dyspareunia
Some may notice change in libido (sexual desire)
Breast atrophy
Loss of protective effect of estrogen on the cardiovascular and skeletal systems
How does the menstrual cycle change in menopause?
Discuss the pathophysiology of hot flashes.
What is dyspareunia?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

42. Psychological and Cultural Variations
Can threaten the woman’s feelings of health and self-worth
Liberation from monthly periods
Ends fear of unwanted pregnancy
Discuss the American culture and how it affects women who are experiencing menopause.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

43. Treatment Options Exercise
Increase in calcium, magnesium, and high-fiber diet
Hormone replacement therapy (HRT), which may increase risk of heart attack and stroke, is based on the individual patient and discussions with her health care provider
Complementary and alternative therapies
Prevention of osteoporosis
Discuss the pros and cons of HRT.
What are examples of complementary and alternative therapies? Discuss side effects for each.
How can you prevent osteoporosis?
Audience Response Question #3
Hormone replacement therapy increases a woman's risk of breast cancer.
1. True
2. False
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

44. Nursing Care of the Menopausal Woman
Determine woman’s understanding of risk/benefits of HRT
Teach signs and symptoms to report; i.e., vaginal bleeding that recurs after cessation of menses, vaginal irritation, signs of UTI
Teach woman how to take prescribed medications correctly and side effects to report
Teach value of weight-bearing exercises
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

45. Pelvic Floor Dysfunction
Occurs when the muscles, ligaments, and fascia that support the pelvic organs are damaged or weakened
Can result in
Vaginal wall prolapse
Cystocele
Rectocele
Uterine prolapse
Kegel exercises
Treated with surgery or pessary
Urinary incontinence
How is a cystocele different from a rectocele?
Discuss urinary incontinence and how it is affected by the pelvic floor muscles.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

46. Nursing Care for Pelvic Floor Dysfunction
Instructing the woman on
The use of exercises
Diet
Prevention of constipation
Adequate fluid intake
What are pelvic floor exercises?
Give examples of natural methods to prevent constipation.
What types of fluids should a woman take and avoid?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

47. Other Female Reproductive Tract Disorders
Uterine fibroids, also known as leiomyomas
Benign growth of uterine muscle cells
Grow under influence of estrogen
Result in irregular bleeding, pelvic pressure, dysmenorrhea, menorrhagia
How do uterine fibroids affect the uterus?
Discuss the pathophysiology of irregular bleeding, pelvic pressure, dysmenorrhea, and menorrhagia.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

48. Treatment of Fibroids
If asymptomatic, observed and periodically reevaluated by health care provider
Hormones
Surgical interventions
Myomectomy
Myolysis
Embolization
Hysterectomy
Discuss how fibroids are monitored by the health care provider.
How are hormones used in treating fibroids?
Describe each surgical intervention.
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

49. Ovarian Cysts
Follicular ovarian cysts develop if follicle fails to rupture and release its ovum during the menstrual cycle
Lutein cyst occurs after ovulation, the corpus luteum fails to regress
Ovarian cyst that ruptures or becomes twisted, cutting off blood supply, causes pelvic pain and tenderness
Diagnosed by transvaginal ultrasound
Laparotomy is the treatment of choice
What is a laparotomy procedure?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

50. Cultural Aspects of Pain Control
Pain is the fifth vital sign
Culture can influence the expression of pain
Ethnicity can affect drug metabolism
Diet can affect drug absorption
CAM can affect action of prescribed drugs
Pain clinics are available
Some cultural groups will not report embarrassing side effects of drugs
Nurses must understand the cultural influences on pain expression
Why is pain considered the fifth vital sign?
Give an example of how one’s culture influences the expression of pain.
Why would a woman’s culture make her hesitate to report a drug’s side effects?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

51. Question for Review
What contraceptive method provides protection from pregnancy as well as sexually transmitted infections?
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.

52. Review Objectives Key Terms Key Points Online Resources
Critical Thinking Question
Review Questions
Elsevier items and derived items © 2011, 2007, 2006 by Saunders, an imprint of Elsevier Inc.