NURSING CARE OF CLIENTS WITH REPRODUCTIVE HEALTH PROBLEMS ADULT WOMEN
Mastitis •
Infection of the breast usually caused by Staphylococcus aureus
•
Risk factors: plugged ducts, untreated engorgement, cracked nipples, missed feedings, excessive fatigue, decreased resistance to infection
•
Common occurring in 5%!"% of breastfeeding #omen
•
$ost common in rst month
•
Recurrences occur in &%!'% of #omen and commonly ()5%* leads to lactation cessation
Mastitis •
Infection of the breast usually caused by Staphylococcus aureus
•
Risk factors: plugged ducts, untreated engorgement, cracked nipples, missed feedings, excessive fatigue, decreased resistance to infection
•
Common occurring in 5%!"% of breastfeeding #omen
•
$ost common in rst month
•
Recurrences occur in &%!'% of #omen and commonly ()5%* leads to lactation cessation
Mastitis — History and Physical Exam •
ever, di-use myalgias, ./u0like1 symptoms, breast pain
•
2edge0shaped, tender, erythematous, usually unilateral
•
3pper, outer 4uadrant most common
Mastitis Treatment •
6 768 stop breastfeeding on the a-ected side, empty the breast
•
If mild, symptoms occur for less than )+ hours and may attempt to resolve #ith fre4uent nursing or pumping and supportive measures including bed rest, /uids, analgesics
•
9ntibiotic options include dicloxicillin 5"" mg po 4id cephalexin 5"" mg po 4id, or clindamycin ;"" mg po 4id for !" to !+ days
•
6bserve carefully for signs of abscess formation
Endometriosis •
Presence of endometrial tissue outside uterus (ectopic) –
•
Found on ovaries, ligaments, colon, sometimes lungs
Responds to cyclic hormonal variations –
Grows and secretes then degenerates, sheds and bleeds •
–
What is the problem (Where does it go)
!lood irritating to tissues " inflammation and pain •
Recurs w# e# cycle w# eventual fibrous tissue –
•
$auses adhesions and obstruction
%iagnosis confirmed w# laparoscopy
Endometriosis •
&nfertility results from – 'dhesions –
•
chocolate cyst* develops on ovary –
•
pulling uterus out of normal position !locage of fallopian tubes Fibrous sac containing old brown blood
Primary manifestations –
%ysmenorrhea •
–
+ore severe e# month
Painful intercourse if vagina and supporting ligaments affected by adhesions
Endometriosis •
$ause not established –
•
-reatment – –
•
+igration of endometrial tissue up thru tubes to peritoneal cavity during menstruation, development from embryonic tissue at other sites, spread thru blood or lymph, transplantation during surgery ($section) all possibilities .ormonal suppression of endometrial tissue /urgical removal of endometrial tissue
Pregnancy and lactation delay further damage and alleviate symptoms
Endometriosis
Pelvic &nflammatory %isease (P&%) •
$ommon infection of reproductive tract –
•
&ncludes0 – – – –
• • •
Particularly fallopian tubes and ovaries $ervicitis (cervi1) Endometritis (uterus) /alpingitis (fallopian tubes) 2ophoritis (ovaries)
&nfection either cute or chronic /hortterm concerns0 peritonitis, pelvic abscess 3ongterm concerns0 infertility, high ris of ectopic pregnancy
P&%4Pathophysiology •
5sually originates as vaginitis or cervicitis –
•
2ften involves several causative bacteria
5terus fallopian tube –
Edema, fills w# purulent e1udate • •
2bstructs tube and restricts drainage into uterus E1udate drips out of fimbriae onto ovaries and surrounding tissue –
•
Peritoneal membrane attempts to locali6e but peritonitis may develop » 'bscesses may form7 lifethreatening lifethreatening » $ause septic shoc
'dhesions affect tubes and ovaries –
3ead to infertility and ectopic pregnancies
P&%
P&%4Etiology •
'rise from se1ually transmitted diseases – –
• •
Prior episodes of vaginitis or cervicitis precedes development &nfection acute during or after menses –
•
Gonorrhea $hlamydiosis
Endometrium more vulnerable
$an also result from &5% or other contaminated instrument –
$an perforate wall and lead to inflammation and infection
P&%4/igns and /ymptoms •
3ower abdominal pain (8 st indication) –
• • • •
/udden and severe or gradually increasing in intensity
-enderness during pelvic e1ams Purulent discharge at cervi1 %ysuria Fever and leuocytosis can occur –
%epends on causative organism
P&%4-reatment • 'ggressive –
•
$efo1itin, do1ycycline
Recurrent infections common –
•
antibiotics
/e1 partners should be treated as well
Followup appt to ensure eradication
!enign -umors0 2varian $ysts •
9ariety of types –
Follicular and corpus luteal cysts common •
• •
5sually multiple fluidfilled sacs under serosa that covers ovary +ay become large enough to cause discomfort, urinary retention, or menstrual irreg –
!leeding if ruptures •
–
•
%evelop unilaterally in both ruptured and unruptured follicles
$ause even more serious inflammation
Ris of torsion of the ovary
5ltrasound and laparoscopy to &% cyst
2varian $ysts
$979<=$=78 6 9>6R8I67
8hreatened 9bortion
Conservative #ith bed rest and reassurance till bleeding stops? Sexual intercourse best avoided? ollo# up #ith 3@8R9S6370presence of fetal cardiac activity predicts good outcome in '5%of cases? Aormone therapy 0+""mg natural progesterone in )divided doses orally or vaginally on empirical basis? 9nti if mother is Rh negative and
Inevitable 9bortion Immediate evacuation of pregnancy? (If duration of pregnancy less than !) #eeks0suction evacuation and greater than !) #eeks oxytocin infusion?* Shock0resuscitation #ith iBv /uids and blood transfusion? rophylactic antibodies and anti0?
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Suction abortion
Incomplete 9bortion
Resuscitation if patient is in shock and evacuation by suction evacuation? If the os is closed <=! tablets are kept in vagina for ripening the cervix? rophylactic rophylactic antibodies and anti
Complete abortion
Conservative 9nti not indicated if pregnancy is less than !) #eeks and there #as no operative intervention?
$issed 9bortion
3terus evacuated as soon as possible? 9 donor should be kept ready? If uterine siDe is less than !) #eeks of gestation <=! tablets kept in vagina results in spontaneous expulsion #ithout the need of surgical intervention? If more than !) #eeks, E th or !)th hourly <=! tablets used vaginally results in spontaneous expulsion or extra amniotic ethacridine acetate?
Septic 9bortion
olice notication if a criminal abortion is suspected? $ild cases0broad spectrum antibiotics are started and uterus evacuated? Severe cases0maintenance of perfusion and ventilation? IBv infusion and CF line is inserted >lood transfusion 6xygen given by nasal catheter?
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CF line
Septic 9bortion(contGG??*
9ntibiotics commenced after taking a high vaginal s#ab? 9mpicillin,
Recurrent $iscarriage
Due to cervical incometence
Management is be cervical cerclage if there is a well documented history otherwise serial follow up is done with transvaginal ultrasound for early signs of incompetence.Cervical cerclage is usually delayed upto 12-14 weeks so that miscarriage due to other causes can be eliminated. Sonography is done to conrm live fetus and if there is infection!it should be treated and se"ual intercourse should be avoided.
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Cerclage
!?$conaldHs Cerclage atient is in lithotomy position and cervix is exposed #ith SimHs speculum?8he cervical lips are held #ith sponge holding forceps and a purse string suture #ith a non absorbable material like black silk is taken all around the cervix? isadvantage suture may be belo# internal os?
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$conaldHs cerclage
)?$odied ShirodkarHs cerclage? Small transverse incision is made on anterior lip of cervix at cervicovaginal unction )cm above the external os?>ladder is then pushed up and a suture of black silk or mersilene tape is passed from anterior to posterior aspect submucosally using ShirodkarHs or any curve bodied needle?) ends of the suture are pulled and tied
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ShirodkarHs cerclage
;?8ransabdominal cerclage one in cases of repeated failure of vaginal approach and cervix is inaccessible isadvantage0Caesarean section In case of miscarry cerclage has to be removed at laparotomy?
ost operative care
>ed rest for +& hours 9ntibiotic cover 9void sexual intercourse Cerclage is removed at ;J #eeks or at the onset of labour ,if not it can result in rupture uterus?
Ot!e" ca#e# o$ "ecu""ent mi#ca""ia%e
Chromosomal abnormalities0karyotyping of both parents and prenatal diagnosis in the next pregnancy? 3terine factors0hysteroscopic resection in case of a septum or division of the adhesion in 9shermanHs syndrome? $yomectomy in case of broid? 9@9 Syndrome0Combination of lo# dose aspirin and lo# $2 heparin as soon as pregnancy is conrmed?9spirin preconceptionally? Inherited thrombophilia0@o# dose aspirin and heparin?
Induced abortion
8A= $=IC9@ 8=R$I798I67 6 R=<797CK 9C8, !'J!
&Act No' () o$ *+,*-
&*.t! Au%u#t *+,*-
9n 9ct to provide for the termination of certain pregnancies by registered $edical ractitioners and for matters connected there#ith or incidental thereto?
>e it enacted by arliament in the 8#enty0second Kear of the Republic of India as follo#s :0
*'
S!o"t title0 e1tent an2 commencement 3
8his 9ct may be called the $edical 8ermination of regnancy 9ct, !'J!?
It extends to the #hole of India except the State of Mammu and Nashmir?
It shall come into force on such date as the Central
4'
De5nition# 6 In this 9ct, unless the context other#ise re4uires, 0
.guardian1 means a person having the care of the person of a minor or a lunatic
.lunatic1 has the meaning assigned to it in section ; of the Indian @unatic 9ct, !'!) ( + of !'!)*
(d* .registered medical practitioner1 means a medical practitioner #ho possesses any recogniDed medical 4ualication as dened in clause (h* of section ) of the Indian $edical Council 9ct, !'5E, (!") of !' 5E*, #hose name has been entered in a State $edical Register and #ho has such experience or training in gynaecology and obstetrics as may be prescribed by rules made under this 9ct?
Place where pregnancy may be terminated - :o termination of pregnancy shall be made in accordance with this 'ct at any place other than a hospital established or maintained by Government, or a place for the time being approved for the purpose of this 'ct by Government;
Premenstrual Syndrome (PMS) • •
A cluster of symptoms that regularly occur several days prior to onset of menstruation More frequently in thirties and forties
Etiology •
Cause is not clearly understood
•
Attributable to water retention, estrogen – progesterone imbalance, psychological factors or dietary deficiencies
Signs and Symptoms •
Irritability
•
Sleeplessness
•
Fatigue
•
epression
•
!eadaches
•
"ertigo
•
Abdominal bloating or weight gain
Diagnostic Procedures •
#eep a $ournal recording
•
%valuation of estrogen and progesterone levels
•
&lood tests to rule out anemia
Treatment •
A reduction of salt inta'e for ( wee's prior to menses to minimi)e water retention
•
Avoid coffee, nicotine, and alcohol
•
*roper diet and e+ercise and rest
•
eduction of stress and rela+ation techniques
Prognosis •
"ariable
Prevention •
-o 'nown prevention
Endometriosis •
Appearance and growth of endometrial tissue in areas outside endometrium, the uterine cavity.s lining
•
Misplaced endometrial tisse in pelvic area
Etiology •
Cause is not 'nown
Signs and Symptoms •
ysmenorrhea occurs, with pain in lower bac' and vagina
Diagnostic Procedures •
/aparoscopy
Treatment •
!ormone therapy
•
Surgery to include uterus, cervi+, ovaries, and fallopian tubes
Prognosis •
"aries
•
*rimary complication is infertility
Prevention •
0se sanitary nap'ins rather than tampons
Pelvic Inflammatory Disease •
Acute, or subacute, or a recurrent or chronic infection of the fallopian tubes, ovaries, and ad$acent tissues
Etiology •
*arturition
•
Infections from -1 gonorrhoeae, C1 trachomatis, *seudomonas, and %1 coli
•
Iatrogenic
•
Coni)ation
•
Most common in young nulliparous women
Signs and Symptoms •
Sudden pelvic pain
•
*urulent and foul2smelling vaginal discharge
•
Fever
•
Se+ual dysfunction
Diagnostic Procedures •
0ltrasonography used to identify a uterine mass
Treatment •
Antibiotics
•
Surgery may be necessary to prevent septicemia
Prognosis •
3ood when treated early
Menopause •
4he cessation of menses and ovarian function
•
ecrease in estrogen levels
•
-ot a disease
Etiology •
5ccurs naturally in women between ages 67 and 87
Signs and Symptoms •
Menstrual irregularities
•
ecrease in flow
•
!ot flashes
•
-ight sweats
•
4achycardia
•
/oss of elasticity in s'in
•
eduction in si)e and firmness of breast
Diagnostic Procedures •
&lood serum levels chec'ed for increased production of follicle2stimulating hormone 9FS!: and luteini)ing hormone 9/!:
Treatment •
!ormonal replacement therapy if needed
Prognosis •
3ood
Prevention •
Cannot be prevented but emotional swings occur
3terine rolapse repared by: Cheng Chan $ara
enition
Ute"ine P"ola#e is the do#n#ard displacement of the uterus into the vaginal canal or a gradually descends of the uterus in the axis of the vagina taking the vaginal #all #ith it?
3sually, prolapse is rated by degrees:
irst0degree prolapse: the cervix rests in the lo#er part of the vagina? Second0degree prolapse: the cervix is at the vaginal opening? 8hird0degrees prolapse: the uterus protrudes through the introitus?
irst degree prolapse
Second degree prolapse
8hird degree prolapse
=tiology
Stretching of muscle and brous tissue? eg? regnancy and childbirth? Increased intra0abdominal pressure as a result of chronic coughing, lifting of heavy obects and obesity, place pressure on the pelvic /oor? 9 constitutional predisposition to stretching of the ligaments as a response presumably to years in the erect position? $enopause and ageing increase the risk of prolapse? (The female hormone estrogen plays an important role in maintaining the strength
Clinical $anifestation
eeling like you are sitting on a small ball iOcult or painful sexual intercourse re4uent urination or a sudden urge to empty the bladder @o# backache 3terus and cervix that stick out through the vaginal opening Repeated bladder infections eeling of heaviness or pulling in the pelvis Faginal bleeding
8reatment
Va%inal e##a"78 8his device ts inside your vagina and holds your uterus in place? 3sed as temporary or permanent treatment, vaginal pessaries come in many shapes and siDes?
8reatment (cont?*
Su"%e"78 Several di-erent types of surgery can be used to treat a severe genital prolapse? 8hese procedures include: <
surgery to repair the tissue that supports the prolapsed organ < surgery to repair the tissue around the vagina < surgery to close the opening of the vagina < surgery to remove the #omb (hysterectomy*
Collaborative Care
preventive measures: =arly visits to AC provider P early detection 8each NegelHs exercises during period preoperative nursing care: 8horough explanation of procedure, expectation and e-ect on future sexual f(x* @axative and cleansing edema (rectocele* independently, at home a day prior procedure erineal shave prescribed also @ithotomy position for surgery postop nursing care:
t? is to void fe# hours after surgery catheter if unable (after E hrs*
Infections of the Female Reproductive Tract • /imple vaginitis
Etiology#pathophysiology • •
$ommon vaginal infection $ausative organisms0 E. coli 7 staphylococcal7 streptococcal7 T. vaginalis7 C. albicans7 Gardnerella
$linical manifestations#assessment • • •
&nflammation of the vagina Cellow, white, or grayish white, curdlie discharge Pruritus and vaginal burning
Infections of the Female Reproductive Tract • /imple vaginitis (continued)
+edical management#nursing interventions • •
%ouching 9aginal suppositories, ointments, and creams
•
2rganismspecific
/it6 baths • 'bstain from se1ual intercourse during treatment • -reat partner if necessary
Infections of the Female Reproductive Tract • $ervicitis
Etiology#pathophysiology •
$linical manifestations#assessment • • •
&nfection of the cervi1 !acache Whitish e1udate +enstrual irregularities
+edical management#nursing interventions •
9aginal suppositories, ointments, and creams7 organismspecific
Disorders of the Female Reproductive System • 9aginal fistula
Etiology#pathophysiology • 'bnormal
$linical manifestations#assessment •
opening between the vagina and another organ
5rine and#or feces being e1pelled from vagina
+edical management#nursing interventions • • •
2ral or parenteral antibiotics %iet0 high protein7 increase vitamin $ /urgery0 Repair fistula7 urinary or fecal diversion
Figure 1-1!
(From .erbst, ';3;, et al; 8==HI; $omprehensive gynecology; > rd ed;I; /t; 3ou is0 +osby;)
-ypes of fistulas that may develop in the vagina and uterus;
Disorders of the Female Reproductive System • $ystocele and rectocele
Etiology#pathophysiology •
$ystocele
•
%isplacement of the bladder into the vagina
Rectocele
Rectum moves toward posterior vaginal wall
Figure 1-1
(From 3ewis, /;+;, .eitemper, +;+;, %irsen, /;R; @AA BI; Medical-surgical nursing: assessment and management of clinical problems. Bth ed;I; /t; 3ou is0 +osby;)
"# $ystocele; $# Rectocele;