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Sexual Transmitted Diseases (STDs/STIs) Prepared by: Elham Ahmed Abdalla Supervisor: Dr Bothyna Bassynie 1.

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Presentation on theme: "Sexual Transmitted Diseases (STDs/STIs) Prepared by: Elham Ahmed Abdalla Supervisor: Dr Bothyna Bassynie 1."— Presentation transcript:

1 Sexual Transmitted Diseases (STDs/STIs) Prepared by: Elham Ahmed Abdalla Supervisor: Dr Bothyna Bassynie 1

2 content Objectives Introduction Pathological vaginal discharge Candidiasis Trichomoniasis Chlamydia Venereal diseases Virus infections Nursing process 2

3 Objectives At the end of this presentation the student will be able to: Recognize the types of sexual transmitted infections. Recognize and assess women with sexual transmitted diseases. Know the pathological vaginal discharge related to sexual transmitted diseases. Identify the risk factors. 3

4 Cont. Know the different signs & symptoms of each Sexual transmitted infection. Know the factors increase the prevalence of STDs. Know the treatment of sexual transmitted diseases. Identify the particular nursing care for each disease/problems. Identify the nursing process. Know the preventive measures. 4

5 Cont. Know the treatment of sexual transmitted diseases. Identify the particular nursing care for each disease/problems. Identify the nursing process. Know the preventive measures. 5

6 INTRODUCTION Sexual transmitted infections constituted one of the major health problems facing the world. Over recent years the prevalence of these diseases has increased at alarming rate. Prevalence 1in5 adult, 1in6 teenagers. 6

7 Cont. Some of these infections linked with cervical carcinoma and HIV infection. The factors Increase STDs: Short duration partners relationship. Increase in world population, increase in those at risk. Diverse sexual practices making diagnosis and treatment more complicated. 7

8 Cont. Increase mobility of population(contact tracing more difficult). Incompliance use of barrier methods. Difficulties in relation to control include: Asymptomatic. Long interval between the person becoming infectious and becoming aware of having disease. 8

9 Cont. Some symptoms not related to genitalia. Failure to produce an antibodies response sufficiently to protect against further infection. Poor heath (venereal diseases). High Risk Group: Age (60%). Prostitutes. Homosexual &Bisexual. 9

10 Estimated Burden of STDs in US STD Incidence Prevalence Chlamydia 3 million 2 million Gonorrhea 650, Syphilis 70, Trichomoniasis 5 million --- HSV 1 million 45 million HPV 5.5 million 20 million Hepatitis B 77, ,000 HIV 20, ,000 10

11 Two basic types of STDs Bacterial : Viral Syphilis. Herpes simplex. Gonorrhea. Hepatitis B. Chlamydia. HIV Chancroid. HPV 11

12 How are STDs spread Skin to skin contact. Oral sex, and kissing (herpes, syphilis, gonorrhea, hepatitis B). Anal sex. Sexual intercourse. Drug abuse Sharing personal things(towels, shaving instrument). 12

13 How can STDs harm the body By causing: Abnormal discharge. Abscess. Rashes. Blindness. Brain damage. Liver damage. Cancer 13

14 Cont. Pelvic inflammatory disease. Sterility in both. Tubal pregnancy. Miscarriage. Still birth. Premature birth. Deformities(adult, newborns). Death(HIV, hepatitis B, and syphilis). 14

15 PREVENTION In Islamic public health measures: Personal hygiene, marriage, banish with illegal sexual intercourse, religious values. In Bible public health measures are described to control the spread of the diseases (the suggestion of killing all women likely to be source of infection). 15

16 Cont. Know that sexual activity provides potential contact with STDs and precautions reduce risk. Avoid sexual intercourse with man who has discharge. Avoid unsafe sex practices. Use condom un till disease is fully treated. Periodic screening for STDs. Ask for partners cooperation. 16

17 CONT Recognize individuals at high risk. When caring for patients use appropriate barrier precautions. Apply all universal precaution when expose to body fluids of high risk. 17

18 Pathological Vaginal Discharges Candidiasis or moniliasis (thrush) : 2 nd most common STDs Cause by; Candida Albicans is yeast – like fungus. The commonest form is vulvitis, often associated with Diabetes & pregnancy The feature: small spores Other sites: Nose, mouth, throat, skin and bowel. 18

19 Risk Factors Lower resistance to infection.(immunosuppressant therapy) Lowering of the vaginal PH.(by using antibiotic & combined oral contraceptive pills) Glycoseuria (High in pregnancy). Humidity and poor hygiene. K-Y jelly used for intercourse Women how use the diaphragm. 19

20 Cont. In men usually sexually transmitted but in women other factors should be consider. Diagnosis: Microscopic test: Gram- positive spores & mycelia can be detected. Swab for culture. 20

21 Signs and Symptoms Incubational period 1-90 days In some women and most men are asymptomatic. Vulval pruritus (increased by warm). Vaginal discharge, white- cottage- cheese-like in consistency, its removal from the vaginal wall leaves a raw area Alternatively: Thin, watery or purulent discharge. 21

22 Cont. Dysuria. Dyspareunia. In male small red spots or curd- like plagues. Treatment: 100mg clotrimazole pessary for 6 nights & 1%Clotrimazole cream for vulva and perineum 2-3 times daily. 22

23 Cont. Alternatively: 1-2 Nystatin pessary (100,000 i.u.) for 14 nights. Nystatin cream (100,000 i.u.) externally 2-4 times daily For male: Warm saline wash. Clotrimazol cream. 23

24 Nursing Care Advise: -Use cotton underwear. -Avoid vaginal contamination after defecation. -Use the pessary and cream over same time. -Avoid humidity -Treatment should continued during menstruation. -Change method of contraceptive. -Personal hygiene. 24

25 Trichomoniasis (Trike or T.V.) One of the most commonest sexual transmitted diseases. Causative organism: Trichomonas vaginalis, an oval flagellate protozoon. Transmission: 1- sexual intercourse. 2- contaminated towels infects the lower genito- urinary tract. 25

26 Signs & symptoms Some are Asymptomatic. Incubation period 4-21 days. Vaginal discharge: - offensive(fishy smelling). - Watery, yellow-green and frothy. -possibly profuse. Vulval pruritus and inflammation. 26

27 Cont. Dysuria. In men: un common Urethral discharge. Dysuria. Prostatitis(rare). Balanitis(rare). Dyspareunia in both. 27

28 Diagnosis Microscopic test: the organism and the movement of its four flagellate and undulating membrane can be seen. Swab for culture. By examination: running finger along the anterior vaginal wall the examiner may milk discharge from skenes tubules. 28

29 Treatment 400 mg tablets metronidazole twice /day after meals for 5days During pregnancy 1 st trimester 100 mg clotrimazole pessary each night for 6 nights with 1% clotrimazole cream 2-3 times daily. Partner should be treated over same period. 29

30 Nursing care Personal hygiene. Avoid alcohol intake during treatment (unpleasant test, gastrointestinal disturbances & giddiness). Intercourse should be avoided un till the swab is negative. Partner should be treated routinely. 30

31 Cont. Chlamydia: Caused by Chlamydia trichomatis. Commonest cause of genital infection in both sexes. Only survive inside the cells of its host. More closely resemble a bacteria than virus. High risk group women years age with multiple partner. Those who do not consistently use condoms. 31

32 Signs & symptoms Asymptomatic. Thin Yellowish or purulent vaginal discharge (cervicitis). Dysuria. (urethritis 40%). Chronic lower abdominal pain (pelvic inflammatory disease, major cause). 32

33 SYMTOMS OF CHLAMYDIA 33

34 diagnosis Swab for culture. Direct immuno-fluorescence detect monoclonal antibodies for Chlamydia (expensive). Enzyme-linked immunosorbent assay(ELISA). Treatment: Erythromycin 500 mg 4 times daily for 14 days(in pregnancy) 34

35 Cont. Doxycycline, 100mg, twice/day for 7 days Azithromycin single-dose Oflaxacin, 400mg twice/day for 7 days. 35

36 Complications Infertility. Tubal pregnancy. Infection of Bartholin's glands. Trachoma Conjunctivitis Blindness. In men: Epididmo-orchitis Gonococcus urethritis. 36

37 HARMFUL EFFECTS OF CHLAMYDIA 37

38 Virus Infections Herpes Simplex: The prevalence of this disease is rapidly increasing. Three-quarters of adult population have antibodies to this virus, indicating that they have been infected Episode may be primary or recurrent. Wide spread on vulva, vagina and cervix Commonly affecting mouth, pharyngeal, nose, genital area. There are 2 types : type 1 (HSV-1), type 11(HSV-11). Causative organism: Herpes virus hominis. 38

39 Signs & Symptoms Incubation period 2-21 days. Painful vesicles develop in to multiple ulcer. Small, irritant blisters on the perineum. Small red painful erosions (the base is not hard). Dysuria (urine irritating sores). Urine retention. Women may experience a purulent vaginal discharge. 39

40 SYMPTOMS of HERPES, 40

41 Cont. Psychological distress (contaminated, difficult to initiate future partner relationship, transmitted to the neonate with disastrous consequences). Type 1 oral lesions(cold sores) less common. Type 11 genital lesions. Primary attack 60% of people develop influenza- like symptoms(headache, backache, 41

42 Cont. (muscle pain & pyrexia, painful enlargement of local lymph glands). THEN The virus lies dormant in nerve ganglia. 2 nd attacks occur in about 70% of people. Occur up to 3 weeks after ecquisition. Recurrences is less frequent, and resolve more rapidly. Sacral nerves may involve. 42

43 Diagnosis Take adequate sexual & travel histories(common in tropical countries). Culture; collecting serum from vesicle with small-gauge needle & syringe or Appling cotton tipped swab to ulcers. Serological test (distinguish b/w type1 & type11, antibodies). 43

44 Treatment: Antiviral treatment: Aciclovir. Valaciclovir, famciclovir 200 mg 5 times/day for 5 days. Aciclovir cream 5% applied to the lesions 5 times /day for 5 days. Topical 5% Idoxuridine 4 times daily for 4 days (inhibits viral replication by altering its DNA therefore not to be used during pregnancy, near to conceive, during lactation). 44

45 Cont. Simple analgesics Local anesthetic (lignocanine gel applied to sore area). Nursing care: Sensitive discussion and counseling are essential Several follow up are needed. Advise patient herpes is likely even if the swab is negative. 45

46 Cont. Return for further culture if any similar lesion occur. Infection control measures when collecting the sample for investigation. Encourage frequent warm saline washes ( 1 teaspoonful salt in 1 paint water) relive pain & prevent 2 nd infection. 46

47 Cont. Relive pain by give analgesic, local anesthetic cream, warm salt washes. Exposure to air (speed healing). Patient with recurrent episode not need antiviral treatment just clean lesions with salt and avoid sexual intercourse. 47

48 Cont. Prevention measures: Avoid contact between other people and open or newly healed lesions. Avoid traveling before the lesion healed completely. Avoid using sharing towels(asymptomatic persons). Treat symptomatic partner. 48

49 Cont. Pregnant women with history, vulva & vaginal swab should be taken weekly from 36 weeks gestation. Improvement of lower socio-economic groups. Vaccine. Avoid reactivation by stress, lower resistance to infection, exposure the sites of original lesions to sun light, friction, use poor lubrication) Use sheaths. 49

50 Complications: Risk of cervical carcinoma. (yearly Pap smear test is suggested). Neurological involvement: Septic meningitis. Transverse myelitis. Autonomic neuropathy. 50

51 Cont. Encephalitis. Herpes keratitis- can lead to corneal scarring and blindness particularly treatment use steroid without antiviral. Surgical intervention(C/S). Resolution usually take 1-2 months. 51

52 HARMFUL EFFECTS of HERPES 52

53 Venereal Diseases Usually present as vulvas lesions. Include: Syphilis, Gonorrhea, and chancroid. Common in tropical regions. Gonorrhea (Drip or clap): Is a commonest bacterial sexual transmitted infection. 3-5 million cases /year. Teenage have the highest rate of occurrence. 53

54 Cont. 60% of females and 20%-40% of male dont know they are infected. Despite its increasing prevalence remains difficult disease to diagnose in women. Causative organism: Neisseria gonorrhea- gram-negative, diplococcal intracellular. Thrive in wet, mucus-lined body area (vagina, rectum, genitourinary, and endo cervix. 54

55 Cont. Incubation period: 3-30 days after contact. Transmission: sexual relations Signs and symptoms: Asymptomatic 60% (F) and 40% (M) causing silent epidemic.(103 weeks). Thin- watery or milky discharge, may be yellowish or purulent greenish with foul smelling in female. 55

56 SYMTOMS OF GONORRHEA 56

57 Cont. Pain with burning during urination. Frequent urge to urinate. Cramps in lower abdomen in female. Sore throat. Swelling vulva, urethra, and skenes glands. In male symptoms may only occur in the morning(ignored). 57

58 Diagnosis High power microscopic test: Demonstrate gram negative intracellular diplococcus of fresh smear.(triple swabs, urethral, vaginal, cervical). Swab culture. History. Clinical examination. 58

59 complications Pelvic inflammatory disease Epididymitis. Sterility. Eye infection –blindness. Abscess (Skenes, Bartholines glands). Tubal scaring, ectopic pergnancy. Surgical repair. Endometritis, parametritis. 59

60 HARMFUL EFFECTS OF GONORRHEA Abscess of penis, may rupture and require surgical repair Epididymitis: infection in the sperm-carrying tubes, can lead to sterility (unable to have children) 60

61 Cont. Treatment: May be resistant to antibiotic. Ceftriaxone 125mg im +100mg doxycycline twice/ day for 7 days. Spectinomycin 2g im in single dose. Or ampicillin2-3.5g im. Alternative Oflaxacin 400 mg oral twice/ day for 7 days. 61

62 Cont. Nursing care: Advise: Both sexual partners need treatment over same period. Avoid sexual activity Need for condom use. Follow up till 2 tests are negative. Personal hygiene. 62

63 Venereal diseases Syphilis (pox- bad blood): There has been a surge in syphilis over the last 5 years. It is a systematic sexual transmitted infection, 50% of people dont know they have it. The rate 2-8/100,000 population. Risk Factors: Sexual activity. Lower socioeconomic class. Illicit drug use 63

64 Cont. Causative organism: Treponema palidum- spirochaete, can enter skin & mucous membrane. Transmission: 1-Direct contact with skin lesions. 2-Sexual intercourse. Kissing 3- Through the blood. 4- Through the placenta. Incubation period: 64

65 Cont days after exposure, (3-4 weeks average) lesions may appear 1 year after exposure. Stages of Syphilis: Primary stage: Chancre is located at the point of entry. Highly infectious dull red or yellowish ulcer with hard base. Pain less, may appear at labia, clitoris, cervix common site, penis, lips, tongue, anus, and rare in vagina. 65

66 Primary - SYPHILIS chancres 66

67 Primary SYPHILIS chancres 67

68 Primary- Kissing chancres 68

69 Oral chancres in primary syphilis 69

70 Cont. Chancre healed within 1 month, but infection has not ended. Second stage: 6weeks – 6months after chancre disappear. Later last 3-9 months Any organ system may be affected. Sign & symptoms: 80% of people Low grade Pyrexia. Regional lymph nodes enlarged. 70

71 Cont. malaise, headache. sore throat joint pain. Large genital warts known as condylomata lata. Dull red rashes, non irritant, non vesicular can cover the body, palms and soles. Systemic eruption occur. All sports & ulcers exude infectious serum. 71

72 Cont. Symptoms may disappear without treatment in 23% of people. Some individuals 20-30% experience clinical relapse, lesions reappear. very infectious. hair loss (alopecia), mucous patches on the mucous membrane (tongue, lips, gum and pharynx). 72

73 2 nd - skin rashs 73

74 2 nd - Condylomata late 74

75 2 nd - Alopecia 75

76 2 nd - Mucosal lesions 76

77 Cont. Latent stage: During this stage no manifestation of infection only positive syphilis serology.. Infectious Infection can transmitted to partner. It begins after end of secondary stage and my last for a life time. 77

78 CONT. It begins after end of secondary stage and my last for a life time. Divided into : early and late latency. Early latency :1 st year after the resolution of p.& 2 nd stage lesions. Infectious. Secondary latency: not infectious except pregnant women may transmit infection to her fetus 78

79 tertiary stage Is the destructive stage of the disease. After 5 years if infection untreated, 5% of people affected. Usually are very slowly progressive. Can be life threaten. Non infectious The main types are: 1 - late benign gummata (large open sores, slow to heal). 79

80 Late syphilis - ulcerating gumma 80

81 Late syphilis - ulcerating gumma 81

82 Cont. - Cardiovascular syphilis. - Neurosyphilis. Cardiovascular syphilis: Thoracic aortic aneurysm. Aortic insufficiency. Aortic regurgitation. Neurosyphilis: 82

83 Cont. Meningovascular syphilis with stroke. Tabe dorsalis. General paresis of insane (loss of memory, emotional liability, personal changes, confusion, impaired balance ) Joint degeneration. Urinary retention & constipation. 83

84 Cont. Swelling in skin mucous membrane and bone can be marble- size and may ulcerated. Congenital syphilis complications: Due to vertical transmission. -Eighth nerve deafness. -Interstitial keratitis. - Abdominal teeth. -Meningitis, arthritis -Blindness 84

85 Cont. Deformities (face, jaw, nose, leg, head bone Hand, ect.) Hepatomegaly, spleenomegaly. Convulsion. Hydrocephalus. Mental retardation. Miscarriage, still birth. 85

86 Cont. 70% of primary & secondary syphilis can not prevented unless the mother treated before 20 weeks gestation. Diagnosis: Dark- field microscopic test demonstrate thin spiral bacterium. Serological test: 86

87 Cont. Venereal disease reference laboratory(VDRL). Rapid plasma reagin(RPR). Flourescent treponema antibodies(FTA) (sensitive & specific). Treponema pallidum haemagglutination assay(TPHA). Treponema pallidum particle agglutation (TPPA). 87

88 Cont. History and clinical examination (cervical chancre). Treatment: The treatment of choice is penicillin. Variety of regimens is used. Procaine penicillin 1.2mu injection i.m. daily for 12 days Benzathine pencillin2.4mu injection i.m. repeated after 7days. 88

89 Cont. Doxycycline 100 mg twice/day for 14 days. Erythromycin 500mg four times a day for 14 days. If infection has been more than 1 year treatment for 21 days for penicillin & 28 days for oral regimen. For neurosyphilis : procaine penicillin 2.4mu i.v, combined with probenecid 500mg -4 times/day. 89

90 Cont. Prognosis: VDRL become negative within 2 years. Nursing care: Both partner should be seen by doctor, tested and treated over the same period. Follow instruction exactly for taken medication. Avoid sexual intercourse. Sample for test HIV infection in all patients. 90

91 Cont. Dont share medication with other the amount given only to cure your infection. Follow up the serological test for 2 years to be sure you are completely free of infection. Penicillin- allergic women skin test should be done. Advise patient that flu-like reaction is not always due to medication reaction but an allergic toxic response to treponemapallidum. 91

92 Hepatitis B This virus is present in the blood, and body fluid of those who have been infected. 300 million people infected world wide. 5,000-6,000 death/ year. Transmission: Through blood. Body fluids. Sexual intercourse. 92

93 Cont. Infected needles(drug addicts & tattooed). The most common risk group: Homosexual and heterosexual (30%). Illicit drug use. Prostitutes. Blood and blood products recipients age group 93

94 Cont. People with high risk occupation. Signs and symptoms: Incubation period: days after exposure. Occur within month after contact. Some may have mild or not noticeable symptoms. The degree of infectivity is measure by the presence of viral DNA. 94

95 Cont. Fever, achiness, headache, dizziness, nausea. Vomiting, light or grey colored stool, yellow skin and eyes(jaundice). Pain in liver area(under the ribs). Sever attack in pregnant woman. (immunoSuppressed state) Diagnosis: Serological test for HBV antigen. 95

96 Treatment Supportive and symptoms management. Alpha-interferon therapy. Antiviral (Acyclovir, Zidovudine). Immunomodulatory may used such as corticosteroids, interleukin, thymocin. Mothers who develop acute attack during last trimester of pregnancy or HBe Ag is positive They are in high infectious stage and babies 96

97 Cont. Need to be treated prophlactically with specific immunoglobulin. Give 1 st dose of vaccine within 24 hours after birth, repeated at 1 and 6 months. Neonatal HB is rare, if occur is serious with poor prognosis. Give several dose of immunogolobulin at 1 st 6 months of life. 97

98 Nursing care Universal precautions in relation to blood, body fluids, and procedures. Avoid intrapartum infections. Cord sample may need to be taken to detect the newborn infection state(HBe Ag). Give 1 st dose of vaccine within 24 hours. Encourage test and treat the men who are partner. 98

99 cont Proper disposal of waste product and sharps. Proper collection and transport specimen. Staff should be vaccinated. Protect the baby from becoming carrier and long-term danger (hepatocellular carcinoma, chronic hepatitis, and cirrhosis. Preventive method: HBV vaccine 3doses and 1 boosters 1 month apart. 99

100 Cont. Advise breast feeding mothers: carrier can breast feed. Following acute attack start breastfeeding after baby develop a good level of passive immuinty. 100

101 Cont. Complications: Sever liver damage. Cancer of the liver. Cirrhosis of the liver. Chronic asymptomatic carrier state. Death. Abortion, premature labor. Newborn infection un less treated within hours after birth. 101

102 Human papilloma virus Cause genital warts. Cause cancer in cervix and penis. Rate million. Common under 25 years. 33% of sex –active female carry the virus. Infect the entire genital region, mouth, and throat. 102

103 Cont. Transmission: Skin to skin contact. Sexual intercourse. Anal sex. oral sex. Can infect the newborn. 103

104 Cont. Sign &symptoms: Appear 1-3 months after contact with infected person. 90% a symptomatic. Genital warts flat, raise tiny. Rare may cause itching, burning, bleeding and pain. 104

105 HPV SYMPTOMS May appear 1 to 3 months after contact with infected person GENITAL WARTS – May be flat or raised, invisible, tiny, or large and cauliflower-like RARELY may have: Itching Burning Bleeding pain MALES FEMALES TONGUE (From oral sex) CERVIX (Unseen) MILDSEVERE MILDSEVERE 105

106 Cont. Diagnosis: Clinical examination. Pap smear. Colposcopy or biopsy Treatment: Trichloracetic acid. Cryotherapy. Laser therapy. 106

107 Cont. Complication: Cervical cancer(90%). Blockage of urethra, vagina or anus. Painful intercourse. Surgery Death. New born infections 107

108 Human immunodeficiency virus HIV/AIDS HIV destroys cells in the immune system leaving them unable to fight off diseases and disrupts many cells in the body, brain, heart, lungs, liver, and intestines. Spread by contact with infectious body fluid and blood. HIV is a member of the lentivirus. subgroup of retroviruses. 108

109 HIV / AIDS HIV – HIV / AIDSs AIDS – Acquired Immunodeficiency Syndrome a result of HIV infection 109

110 CONT. Transmitted by certain activities: Sex with infected person. Sharing infected needles and tattooing. From infected mother to baby. From transfusion of blood or blood products. Open mouth kissing. Sharing sex toys. 110

111 Cont. Diagnosis: Serological test for anti-HIV antibodies Western blot is the most widely used confirmatory test for HIV infection. Indirect immunofluorescence assay. All tests measuring the level of CD4 lymphocytes in peripheral blood, normal level > 0.5/l 111

112 Cont. Signs %symptoms: Asymptomatic for 5-10 years. May have flu-like symptoms (may be ignored) Fever, night sweats, swollen glands. Loss of appetite, diarrhea, skin rashes. Window period 6-12 weeks or more: Before HIV antibodies are produced person may be infected but their blood test is negative(false negative). 112

113 Cont. Later signs & symptoms: Significant weight loss Lack of resistance to infection. Shortness of breathing and dry cough. Furry white spots in the mouth. Red or purplish spots on the body(Kaposis sarcoma). Memory or movement difficulties. Painful peripheral neuropathy. 113

114 Cont. Treatment: Palliative care & management 114

115 Nursing Process Assessing: To identify the patients health status, actual or potential problems and needs History includes: personal data, complain, when condition start, sexual relationship, obstetric and neonatal history ect Physical examination: describe the appearance and location of discharge, rashes or ulcers, pain, and any complications 115

116 Cont. Correctly record the findings. Identify the problems and needs Develop the goals related to patients out come. Nursing diagnosis: Analyzing patients data to determine strengths and weakness. 116

117 Cont. Nursing planning/intervention: Described how you carry out the care plan and integrated the doctor prescription with your plan for each nursing diagnosis. Educate patients and their families. On going planning. discharge planning 117

118 Cont. Evaluation: Measure the extent to which the patient achieved out come. Modify the care plan if necessary. Terminate the care plan if fulfill the patient goals and achieve out come. 118

119 References Arlene BURROUGHS. Maternity Nursing. Introductory text,7 th edition Gynaecology by ten teachers. 18 th edition 2006,p Myles. Text book for midwives, eleventh edition.Part 6,p Popmed wibeside. 119


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