1. Nursing Care of the Client: Reproductive and Sexual Health
Chapter13
Nursing Care of the Client: Reproductive and Sexual Health

2. Anatomy and Physiology Review

3. Anatomy and Physiology Review

4. Common Diagnostic Tests
Laboratory tests
Radiologic tests
Biopsy
Dilation and curettage (D&C)
Laparoscopy
Colposcopy
Nocturnal tumescence penile monitoring
Pelvic examination
Schiller test
Ultrasound

5. Pelvic Inflammatory Disease (PID)
Inflammatory process involving:
uterus, fallopian tubes (salpingitis), ovaries (oophoritis)
Chlamydia, gonococcus, streptococcus, staphylococcus, and herpes simplex virus II,
Infections are usually ascending
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6. Pelvic Inflammatory Disease (PID)
Incidence: 100,000 women become infertile Risk Factors: multiple sexual partners, frequent intercourse, IUDs, douching, childbirth. Symptoms: low-grade fever, pelvic pain, abdominal pain, backache, foul-smelling vaginal discharge, nausea/vomiting, dysmenorrhea (painful menstruation), dyspareunia (painful intercourse), and intense pelvic tenderness upon examination.
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7. Pelvic Inflammatory Disease (PID)
Complications
peritonitis
pelvic abscesses
infertility
ectopic pregnancies
Acutely ill client may require hospitalization for IV antibiotic therapy.
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8. Pelvic Inflammatory Disease (PID)
Pharmacological-Antibiotics
doxycycline monohydrate (Vibramycin)
metronidazole (Flagyl)
cefoxitin (Mefoxin)
clindamycin (Cleocin)
gentamicin (Garamycin)
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9. Pelvic Inflammatory Disease (PID)
Nsg Mgt: nonjudgmental attitude, VS, I&O, BR BRP (semi-Fowler's) Teach proper pericare, hygiene, hand hygiene. Administer antibiotic Assessment: Unprotected intercourse, sexual activity, number of partners, history of contraception, previous vaginal infection, obstetrical history, douching/tampon use.
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10. PID Nursing Diagnoses
Acute Pain related to inflammation of the pelvic structures caused by invasion of pathogens
Deficient Knowledge related to the etiology of the pelvic inflammatory process, treatment regimen, self-care, and preventive measures
Hyperthermia related to physiologic responses to the inflammatory or infectious process
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11. Endometriosis
Growth of endometrial tissue outside uterus Occurs women 30 years, tends to be familial. progressive and recurrent “career woman's disorder” “powder burns” brownish or black lesions. “chocolate cyst” (ovary) Monthly symptoms: backache, painful intercourse, heaviness on the pelvis, and spotting.

12. Endometriosis Assessment
dyspareunia prolonged, excessive menstrual periods frequency, comfort, duration, amount menstrual flow. future plans for childbearing. Assist physician during procedures.
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13. Endometriosis Nursing Diagnoses
Acute Pain related to bleeding from endometrial implants in the pelvic cavity
Anxiety related to treatment options, possible side effects, and infertility
Ineffective Sexuality Patterns, or Sexual Dysfunction, related to altered body function or structure (painful intercourse)
Situational Low Self-Esteem, related to the inability to conceive

14. Vaginitis
Candida albicans (yeast infection) Trichomnas vaginalis (a protozoan) Gardnerella vaginalis (a bacterium) Chlamydia trachomatis (a parasite) Other causes: streptococcus, staphylococcus, gonococcus, and herpes simplex II. Most infections have characteristic discharge, irritation, burning, itching
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15. Vaginitis Candidiasis (monilia)
Predisposing factors: obesity, diabetes, pregnancy, oral contraceptives, antibiotics, bubble baths, frequent douching. Symptoms: thick, white, cheesy/curd-like discharge, musty, sweet odor, itching, irritation. Treatment: miconazole (Monistat), clotrimazole (Mycelex-G, Gyne-Lotrimin), nystatin (Mycostatin).

16. Vaginitis Trichomoniasis
Frequently passed from partner to partner Symptoms: copious green-yellow, foul-smelling, frothy discharge, itching, burning, irritation. Treatment: Metronidazole (Flagyl) taken orally by both partners. abstain from intercourse

17. Vaginitis Gardnerella
Symptoms: asymptomatic or gray-white discharge, strong odor Treatment: Flagyl, tetracycline hydrochloride (Achromycin), ampicillin (Omnipen). Sulfa-based creams

18. Vaginitis Chlamydia
Asymptomatic (associated with infertility) Treatment: oral antibiotics for at least 7 days. repeat culture recommended

19. Vaginitis Assessment
Onset symptoms, menstrual history, contraceptive methods, use of antibiotics, other meds, illnesses, DM, sexual/pregnancy history, hygiene practices. Emphasize the significance of hand hygiene before and after applying vaginal medications. Notify client that her sexual partner should also be treated.

20. Vaginitis Nursing Diagnoses
Acute Pain, related to irritation, excoriation, or ulceration of vaginal tissue
Deficient Knowledge, related to the origin of the infection, prevention, and treatment options
Impaired Tissue Integrity, related to the presence of vaginal discharge, itching, or irritation
Sexual Dysfunction, related to discomfort during intercourse or fear of transmitting the infection to the sexual partner
Risk for Impaired Skin Integrity, related to internal and external irritation from discharge and itching

21. Toxic Shock Syndrome (TSS)
Rare, life-threatening condition
Staphylococcus aureus
Group A streptococcus
Incidence: women under 30
Symptoms: sudden can be fatal-high temperature, vomiting, diarrhea, hypotension, flulike symptoms; malaise, muscle soreness, sore throat, HA, macular erythematous, peeling of the palms/soles.
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22. TSS Medical Mgt
Cultures, blood pressure, IVF, mechanical ventilation, CPAP, dialysis Pharmacological: dicloxacillin sodium (Dynapen), clexacillin sodium (Tegopen), nafcillin sodium (Nafcil), and methicillin sodium (Staphcillin). -for at least 2 weeks

23. TSS Assessment
Use of tampons, contraceptive sponges, sore throat, headache, myalgia, and fatigue, rash, edema, peeling of palms and soles, hypotension, fever, level of consciousness
Nsg Mgt: BR, antipyretics, antibiotics, vital signs, I&O

24. TSS Nursing Diagnoses
Hyperthermia related to inflammatory process Deficient Fluid Volume related to diarrhea, vomiting, fever, and decreased intake Risk for Impaired Skin Integrity related to dehydration and effects of circulating toxins

25. Epididymitis
Sterile or Nonsterile Inflammation Symptoms: sudden severe scrotal pain, warmth, redness, swelling, tenderness, dysuria, pyuria, chills, fever, discharge, blood Treatment: BR, antibiotics, scrotal support, ice Bilateral: can cause sterility. Untreated: tissue necrosis, septicemia, death.

26. Orchitis
Inflammation Testes Causes: gonorrhea, trauma, surgical manipulation, TB, mumps Unilateral: does not cause sterility. Symptoms: sudden scrotal pain/edema, chills, fever, N&V Treatment: BR, scrotal support, ice

27. Prostatitis
Inflammation Prostate Complication of chlamydia/gonorrhea urethritis. May be acute or chronic Difficult to differentiate from prostate cancer Symptoms: perineal pain, fever, dysuria, discharge. Medical Mgt: NO urinary catheter Pharmacological: antibiotics, analgesics, stool softeners.

28. Prostatitis Assessment
History of recent bacterial or viral infection Pain, discharge, dysuria, arthralgia, back pain, scrotal edema, constipation, nausea, emotional needs. Vital signs (especially temperature) Nsg Mgt: BR, scrotum elevated, cold packs, sitz baths, assess pain, athletic support (Amb)

29. Epididymitis, Orchitis, Prostatitis
Nursing Diagnoses Risk for Injury related to worsening of the inflammatory process Deficient Fluid Volume related to nausea and vomiting Acute Pain related to Inflammation Anxiety related to concerns about possible sterility or impotence

30. Fibrocystic Breast
lumpy, nodular, glandular tissue, single or multiple cysts, frequently fluid-filled, yellow-greenish, sticky discharge
Common between 30 and 50 years of age
familial tendency development breast cancer
Difficult to differentiate: cysts, fibroadenomas, and carcinomas (routine mammograms, breast self-examination)
Treatment: biopsy or aspiration, frozen section

31. Fibrocystic Breast Surgical Treatment: aspiration or surgical excision
diagnostic or therapeutic
nurse labels specimen for lab
Pharmacological: vitamin E
Diet: limit or eliminate caffeine
(teas, colas, coffee, chocolate)
Nsg Mgt: BSE, mammogram, firm/supportive bra

32. Fibrocystic Breast Nursing Diagnoses
Deficient Knowledge related to the cause of fibrocystic breast changes and method of breast self-examination Anxiety related to the underlying potential and risk of breast cancer

33. Fibroid Tumors
Fibroids (leiomyomas) Benign tumors in/on uterus Incidence: nulliparous women, more than 35 yo (Prevalant African-American, Mediterranean) Symptoms: menorrhagia, pelvic pressure, dysmenorrhea, abdominal enlargement, constipation Diagnosis: pelvic ultrasound or laparoscopy

34. Fibroids
Medical Mgt: “wait-and-see” observe the growth pattern. Reexamination every 6 months. Surgical: D&C, myomectomy, hysterectomy Diet: iron rich foods Assessment: menstrual flow, dysmenorrhea, pain, pressure, abdominal enlargement, constipation, urinary frequency/urgency.

35. Fibroids
Risk for Deficient Fluid Volume related to excessive blood losses Acute Pain related to pressure on pelvic structures caused by growing tumors and cramping during the menses

36. Benign Prostatic Hyperplasia (BPH)
Progressive adenomatous enlargement of the prostate gland that occurs with aging. Incidence: 90% men older age 70 have BPH Symptoms: partial/complete obstruction, hesitancy decreased force- stream, urinary frequency, nocturia, atony, bacterial growth leads to UTI, eventually lead kidney damage.
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37. BPH Medical Mgt
Diagnostic tests digital rectal examination (DRE), PSA, post-void bladder scan, cystoscopy, rectal ultrasonography, prostate biopsy. Monitor for: hesitancy, urgency, hematuria, UTI. Surgical alternatives: balloon dilation, urethral stent, TUMP, TUNA, retropubic prostatectomy, perineal prostatectomy

38. BPH Surgical Mgt TURP traditional surgical intervention for 90%
resectoscope, general or spinal anesthetic
bladder is continuously irrigated
Open Surgery
suprapubic resection
retropubic prostatectomy
perineal prostatectomy

39. BPH Surgical Mgt
Surgical Complications: hemorrhage, water intoxication, infection, thrombosis, damage to surrounding structures, sexual dysfunction, urinary incontinence. Laser prostatectomy (TULIP) Pharmacological: Finasteride (Proscar) aterazosin hydrochloride (Hytrin), doxazosin mesylate (Cardura), alfuzosin (Uroxatral), tamsulosin Hcl (Flomax).

40. BPH Nsg Mgt Post-op Assessment
Pain, emotional needs, information or reassurance, vital signs
Report hemorrhage, hyperthermia, hypotension, tachycardia immediately
TURP continuous bladder irrigation (CBI)
I&O (subtract irrigant), post void residual,
water intoxication,

41. BPH Nursing Diagnoses
Stress or Urge Urinary Incontinence related to poor sphincter control after catheter removal after surgery Sexual Dysfunction related to surgery

42. Malignant Neoplasms
breast, cervical, endometrial, ovarian, prostate, testicular, penile cancers

43. Breast Cancer
Incidence Key to cure is early detection Painless mass or lump common symptom Symptoms: masses, lumps, thickening, swelling, dimpling, redness, scaliness, irritation; pain, retraction, discharge, unilateral change size, orange-peel appearance (peau d'orange) of the skin
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44. Breast Cancer Risks
Family hx Never had children First child after 30 Never breast-fed Hx fibrocystic breast changes Menstruating before age 10 Obese

45. Breast Cancer
Staging system provides standardized method American Joint Committee on Cancer's TNM system. T = Tumor (the size and how far has it spread within the breast and to nearby organs) N = Nodes (spread to lymph nodes) M = Metastasis (spread to distant organs)

46. Breast Cancer Treatment
Surgical Removal
Lumpectomy or mastectomy
Radiation and chemotherapy
Targeted therapy
Immunotherapy
Photodynamic therapy
Gene therapy
Hyperthermia
Antiangiogenesis therapy

47. Breast Cancer Treatment
Lumpectomy
Simple mastectomy
Modified mastectomy
Radical mastectomy
Lymphedema
Reconstructive surgery

48. Breast Cancer
Pharmacology Antiestrogens Androgens Chemotherapy Agents Alkylating agent Anti-tumor antibiotic Antimetabolites Steroids

49. Breast Cancer Nsg Mgt
BSE Mammogram Fears/concerns -support groups Postoperative care Vital signs Incisional site

50. Breast Cancer
Fear related to breast cancer, possible metastasis, surgery, and disfigurement Disturbed Body Image related to removal of the breast Self-Care Deficit related to limited use and range of motion on the affected side and postoperative discomforts

51. Cervical Cancer Dysplasia change in size/shape of cervical cells
mild, moderate, severe
Abnormal Papanicolaou (Pap) smear
Associated Factors: Sexual habits, smoking, oral contraceptives, immunosuppression, multiple pregnancies, family history, diet low in fruits/vegetables, obesity
Incidence: year olds

52. Cervical Cancer
Symptoms: asymptomatic or abnormal bleeding, thin, watery, blood-tinged discharge to frank bleeding. Contact bleeding after intercourse. Advanced disease is indicated by odor, pain in the lower back and groin, difficulty in voiding, hematuria, and rectal bleeding Two types squamous-cell carcinoma and adenocarcinoma

53. Cervical Cancer
Staging from I to IV Carcinoma in situ (CIS) means that the cancerous cells remain within the cervix The greater the number on the staging table, the more the cancer has metastasized to other structures. Surgical Treatment: conization

54. Cervical Cancer Surgery
Laser surgery Cryosurgery (freezing with liquid nitrogen) Cauterization (burning) Hysterectomy or radical pelvic surgery Radium implants or radiation therapy Chemotherapy

55. Cervical Cancer Nsg Diagnoses
Anxiety related to unknown outcome and possible treatments Sexual Dysfunction related to vaginal bleeding, discomfort, and procedures Impaired Urinary Elimination related to sensory motor impairment from radiation effects

56. Endometrial Cancer Risks
Postmenopausal women, Caucasian, middle class Family history Estrogen replacement therapy Oral contraceptives Never having a child, never having intercourse Obesity Diabetes

57. Endometrial Cancer
Treatments: radiation, radium implants, chemotherapy, surgery, blood transfusion Surgical Interventions: Hysterectomy Subtotal hysterectomy Radical or pan hysterectomy (laparoscopic or abdominal approach)

58. Ovarian Cancer
“The silent killer” Symptoms: vague, ignored, advanced, inoperable stage. Bloating, abdominal or pelvic pain, difficult eating, feeling full quickly, urinary urgency or frequency Incidence: 45 and 65 years old. Nulliparity (never having borne a child), smoking, alcohol use, infertility, high-fat diet

59. Ovarian Cancer Diagnostics
Lower GI series, transvaginal pelvic US, CA-125 paracentesis for cytology, Pap smear, biopsies, D&C, CXR, IVP, KUB, CBC,Schiller's test, colposcopy, laparoscopy, barium enema, bone scan.
Recurrent disease is common
5-year survival rate is 45%

60. Ovarian Cancer Treatment: Total abdominal hysterectomy
bilateral salpingo-oophorectomy or omentectomy
Combination of:
radiation, chemotherapy, immunotherapy, surgery -palliative

61. Ovarian Cancer Pharmacological
Chemotherapy drugs Intraperitoneal chemotherapy Combination chemotherapy PCA pump (continuous low-dose narcotics) Transdermal patches “Brompton's mixture, elixir, or cocktail” tranquilizers, antiemetics, laxatives

62. Ovarian Cancer Nursing diagnoses
Preoperative Fear related to tentative diagnoses, pending surgical procedures, cancer treatment and its side effects, incapacitating or extended illness with resulting dependence, and possible death Postoperative Impaired Skin Integrity related to surgical interventions, radiation, and chemotherapy side effects

63. Prostate Cancer
Incidence (increases with age) Detection: serum prostate-specific antigen (PSA), transrectal ultrasonic examination, DRE, prostatic biopsy. Adenocarcinomas: slow-growing tumors Early symptoms: dysuria, weak stream, frequency. Later symptoms: obstruction or hematuria, anemia

64. Prostate Cancer Treatment
Depends on extent, age of client. Radiation is the traditional alternative to surgery Complications: diarrhea, bowel obstruction, lymphocele formation, edema of the extremities, pulmonary embolism, wound infections, infection, impotence, incontinence, or radiation cystitis. Transrectal assisted radioactive seed implant

65. Prostate Cancer Treatment
Surgical treatment
removal prostate gland
orchiectomy
urethra is anastomosed
perineal or retropubic approach
robotic-assisted laparoscopic radical prostatectomy “da Vinci” system
Pharmacological : Chemotherapy drugs, Hormonal agents

66. Prostate Cancer Nsg Mgt
Annual rectal examination, PSA serum level. back pain, sciatica, frequency, dysuria, nocturia. Post op: Report hyperthermia, hypotension, tachycardia, increased incisional drainage Monitor catheter drainage-color, amount, presence of clots Risk Factors: age over 55 years, family hx, African American, high serum testosterone

67. Prostate Cancer Nursing diagnoses
Urinary Retention related to urethral obstruction, secondary to urethral anastomosis. Bowel Incontinence related to loss of rectal sphincter control because of perineal incision Risk for Impaired Skin Integrity related to incontinence

68. Testicular Cancer
Incidence: 1% of all cancer in men most common ages of 15 and year survival rate 96% Etiology unknown Symptom: small, hard, painless lump Early diagnosis: TSE

69. Testicular Cancer
Surgical removal: testis, spermatic cord, inguinal canal
Pharmacological: chemotherapy and radiation
Nsg Mgt: TSE, anxiety or depression, gynecomastia
Risk for Injury due to infection and hemorrhage related to surgery
Deficient Knowledge related to surgery and post operative care

70. Penile Cancer
Rare, high correlation poor hygiene uncircumcised Chronic irritation carcinogenic. Risk Factors: Hx of STI’s Symptoms: painless, nodular growth (foreskin), fatigue, weight loss. Treatment: penectomy (perineal urethrostomy) Nsg Mgt: emotional support, Elevate, assess pain Post-op Complications: low BP, tachy, incision drainage, redness, swelling; bright red or low urinary output

71. Penile Cancer Nursing Diagnoses
Risk for Injury due to infection and hemorrhage related to surgery
Anxiety related to surgery
Ineffective Sexuality Patterns related to the altered body function or structure

72. Menstrual Disorders Dysmenorrhea “menstrual cramps”
Attitude, analgesics, oral contraceptives
Amenorrhea absence of menstruation
primary or secondary
pelvic examination, pregnancy test
Depo-Provera
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73. Menstrual Disorders Menorrhagia metrorrhagia Polymenorrhea
Oligomenorrhea
Treatment: dilation and curettage (D&C)
blood transfusion, supplemental iron

74. Menstrual Disorders Assessment
Nsg Mgt:
Hypertension, tachycardia. Monitor labs
Acknowledge, Explain, Encourage, Emphasize
Nursing diagnoses
Acute Pain
Decreased Cardiac Output
Fatigue
Disturbed Body Image

75. Premenstrual Syndrome (PMS)
women between 20 and 50 years of age Risk factors multiple life stressors, inappropriate nutritional status, reaction to or side effects oral contraceptive use, sedentary lifestyle, marital status, Hx preeclampsia, multiparity. Symptoms: more than 150 reported Pharmacological Mgt Diet: sugar, salt, caffeine, chocolate

76. Premenstrual Syndrome (PMS)
Nursing Diagnoses
Excess Fluid Volume related to hormonal imbalance and increased sodium or sugar intake
Health-Seeking Behaviors, related to finding methods to cope with symptoms of PMS

77. Menopause
Climacteric: cessation of menstruation. “change of life” range of onset is from 45 to 60 years old, onset is usually gradual Reproductive capability is lost Postmenopause time period Symptoms: vaginal dryness, weight gain, dry skin, stress incontinence, osteoporosis, depression, nervousness, insomnia, “hot flashes”

78. Menopause Pharmacological: ERT Diet: calcium-rich products
Herbal teas, vitamin E, magnesium, primrose oil
Activity: 30-minute 3 times week
Nursing diagnoses
Health-Seeking Behaviors
Decisional Conflict

79. Structural Disorders Female
Cystocele, Urethrocele , Rectocele, Prolapsed Uterus Treatment: restoration structure and function, pessary, hysterectomy, A&P repair, Marshall-Marchette-Krantz Activity: Client Teaching-Kegel exercise Nursing diagnoses: Stress Urinary Incontinence Constipation Risk for Infection Sexual Dysfunction
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80. Structural Disorders Male
Hydrocele: benign, nontender collection fluid, scrotal swelling, surgical excision Spermatocele: benign nontender painless cyst epididymis or rete testis. surgical aspiration or excision
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81. Structural Disorders Male
Varicocele : dilation of veins-scrotum Symptoms bluish discoloration , wormlike mass Complication infertility Torsion Spermatic Cord Symptoms: abdominal/scrotal pain, scrotal edema, nausea/vomiting, slight fever. Treatment: surgical detorsion (untwisting)
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