med surg #2 women pt 1.docx

**Ch. 50 - Assessment and Management of Female Physiologic Processes** **Perimenopause, pg 4451** - The menstrual transition period before menopause that begins on average 4 years before the last menstrual period (usually occurs around 51 years old BUT can begin as early as 35 years of a...

**Ch. 50 - Assessment and Management of Female Physiologic Processes** **Perimenopause, pg 4451** - The menstrual transition period before menopause that begins on average 4 years before the last menstrual period (usually occurs around 51 years old BUT can begin as early as 35 years of age) - S/sx: **Hot flashes, palpitations, irregular menses (can be heavier or lighter),** vaginal dryness, urinary issues - Midlife health issues - **KNOW Contraception**, STD, Sexuality, fertility - **Oral contraception** is preferred as a contraception b/c provide **protection against uterine cancer and ovarian cancer, anemia, pregnancy, s/s of fibrocystic breast dz, and relief of perimenopausal s/s** (book) - Women during this time need to be re-instructed about getting breast exams - **Pregnancy**: continue contraception until menses has completely stopped, b/c they are still at risk for pregnancy - Breast **Menopause** - Permanent physiologic cessation of menses associated with declining ovarian function evidenced **by 12 consecutive months with no menstrual bleeding KNOW** - Most often occurs b/t the ages of 41-59 - **Hormone level change to confirm menopause: Increased FSH and LH** - Menopause starts gradually signaled by changes in menstruation - **Continue contraception until she is 1 year without menses** - Post menopause = the period beginning from about 1 year after menses stops - **KNOW Any postmenopausal bleeding MUST be evaluated, b/c it is associated w/ vaginal malignancy (like endometrial cancer)** - **Must receive recommended screening exams (mammograms/pap smear)** - **Current recommendation for pap smear: every 3 years after 3 or more normal pap smears in a row OR every 5 years if done w/ HPV test** - Clinical Manifestations - **Mood changes** may be due to **lack of sleep** from hot flashes - Breast tenderness (due to fluid retention) - **Increased risk for vaginal infections** - **Hot or warm flashes** due to vasomotor instability (can also cause palpitations), vaginal dryness, HA, thinning hair - **KNOW Increased bone loss** causes increased risk of osteoporosis. So they need calcium supplements, vitamin D, and weight-bearing exercise - **Sleep issues d/t all of these above issues (mainly hot flashes)** - **Entire GU system is changing: vaginal atrophy/fragile, decrease vaginal lubrication can lead to painful sex** - **KNOW vasomotor s/s: Hot flashes, night sweats, dizziness, palpitations** - **KNOW increase in vaginal pH causes increase in vaginal infections. Also b/c of thinning and atrophy of vaginal tissue and decrease in vaginal lubrication** - Education: use lube and drink water **Medical Management** - **Hormone Replacement Therapy \[HRT\]:** prescribed to alleviate symptoms of menopause - Research shows they increase some health disorders such as breast cancer, **heart attack,** stroke and **blood clots** - **Contraindicated in the following: Hx of breast cancer, coronary heart disease, previous TIA/DVT/PE, unexplained vaginal bleeding, active liver disease** - **Estrogen and Progestin** - New recommendations is low dose and for a short period of time until symptoms have passed - **Progestin used to make sure uterine lining sheds (menstrual period) & prevents cancer** - **Estrogen therapy increases risk of heart attacks** - Dosing: 25 days of estrogen with progestin in cycles (10-14 days) - Estrogen + progesterone for women w/ uterus - **KNOW Tx if she has a uterus and ovaries: Estrogen/progesterone therapy (estradiol)** - **KNOW Tx if she does NOT have a uterus and ovaries: Estrogen therapy** - Available routes: oral, transdermal, vaginal or intrauterine - Types: **Estrogen patch + progestin,** creams, suppository, estradiol ring - **Estrogen patches are contraindicated in patients with a history of breast cancer** - **Estrogen patches are replaced once or twice weekly (book)** - Alternative meds: **Paroxetine/paxel, gabapentin, and clonidine** - **KNOW Venlafaxine (SSRI) helps w/ vasomotor symptoms, especially if being kept up at night from hot flashes** - **Used when HRT is contraindicated** - **Paroxetine/Paxel for control of intractable vasomotor s/s** - **Alternative therapies: Black cohosh (hot flashes, nervousness, vaginal dryness) + dong quai (effective in treating hot flashes)**; both used for hot flashes - SE of black cohosh: GI upset, rashes, slight risk for liver damage - B6: has shown to increase mood and serotonin levels and has a positive effect on cognitive function - Vit E: used vaginal for the vaginal dryness - Glucose levels monitoring is important b/c hormonal shifts can trigger low BG, esp. at night causing them to wake up hypoglycemic = INCREASE FOR FALLS **Nursing Management** - Maintaining Bone Health - **Weight-bearing activity like walking to prevent osteoporosis,** Calcium and D3 Supplements - **Maintaining Cardiovascular Health** (more in chapter 21, not in chapter 50) - Maintain a BMI \< 25, stop smoking, fasting BG \< 100, normal BP (untreated), 150 mins of physical exercise/week, DASH diet - Active liver disease, TIA, previous strokes - **Diet: Lower carb and fat intake** - Medication: BB, aspirin, statins, ACE - Nutritional therapy - **Decrease saturated fats, caloric intake, and sugars** - **What education does a newly menopausal woman need?** - Increase whole grains, fruit, fiber, Increase calcium - Average lifespan AFTER menopause is 30-35 yrs - **Monitor BG levels,** Normal sexual function - Patient teaching - **Avoid caffeine, ETOH, spicy foods to prevent hot flashes** - **Seat belts, fall prevention, protective equipment** - **Health promotion interventions for** bone loss (osteoporosis), mood changes, CV health, diet, exercise, no smoking, regular health screenings - Maintain a healthy lifestyle - Use lubricants to help with vaginal dryness; Use a fan OR sleep in a cold room to help with hot flashes (lecture) **Ch. 51 - Management of Patients With Female Reproductive Disorders** **Vulvovaginal Infections** Normal conditions - pH 3.5-4.5: allows destruction of stuff on contact + protects from infection - **Maintained by Lactobacillus acidophilus and glycogen** - Estrogen induces glycogen formation that is broken down into lactic acid which keeps the pH of the vagina low (notes) - **Before menopause the vagina is protected against infection by what?** - Acidic pH, *lactobacillus* *acidophilus* (the dominant bacteria in a healthy vaginal ecosystem) Risk Factors for Vaginal Infection **Chart 51-1** p. 1677 - **Frequent douching, HIV infection, Long-term or repeated use of broad-spectrum antibiotics, steroids (prednisone), Use of oral contraceptives,** Low estrogen levels, Allergies, Diabetes, Oral--genital contact (yeast can inhabit the mouth and intestinal tract), Perimenopause/Menopause, Poor personal hygiene, Pregnancy, Premenarche, Sex with infected partner, Synthetic clothing, Tight undergarments (book) **Vaginitis** - Inflammation or infection of the vaginia - Group of conditions that cause vulvovaginal symptoms - Cause: bacterial vaginosis, douching, bubble baths - S/sx: itching, irritation, burning, abnormal discharge - Table 51-1 p. 1678 - **Comfort measures: Cool compress, cotton underwear, no bubble baths/douching,** no itching, front to back wiping **Candidiasis (pg. 4470)** - Fungal or yeast infection **\[Candida albicans\]** that cause alteration of internal environment increases risk - S/sx: **discharge \[watery or thick/cottage cheese\]** that causes itching/pruritus and irritation **external & internal;** redness, dyspareunia - **s/s worse after menstruation** - **RF: birth control, pregnancy** - Diagnosis: spores and hyphae on microscopic exam/vaginal wet mount, pH is 4-5 - **If pt has 3 or more episodes in a year, check her for uncontrolled DM or HIV (an immunosuppressive disease)** - Treatment: **miconazole (antifungal)**, nystatin, clotrimazole, fluconazole - Inserted into the vagina before bed. treated 1-7 days - PO: one pill relief should be noted in 3 days **Bacterial Vaginosis (pg 4473)** - Overgrowth of anaerobic bacteria and **Gardnerella vaginalis (this is the one the book mentions), haemophilus vaginallis, E. coli** and NO lactobacilli present - Risk factors: douching, smoking, multiple partners, other STDs - S/sx: **heavy discharge gray-yellowish white, fishlike odor**, pH \> 4.7, **itching, burning w/ urination,** dyspareunia - Fish odor is worse after sex - **Diagnosis:** whiff test **and clue cells** - **Whiff test:** add a small amount of potassium hydroxide to the slide with the smear. If it smells fishy then, it's positive - **KNOW Clue cells:** in bacterial vaginosis is the epithelial cells are coated with bacteria - KOH prep - **Complications:** - Dangerous to have during pregnancy, can cause premature delivery, low birth weight, and PROM - **Increase the risk for HIV** - **KNOW Treatment: 1-2 g metronidazole PO BID for 7 days** and/or clindamycin cream/suppositories - **Education:** **avoid alcohol when taking metronidazole** **Trichomoniasis (pg 4474)** - Caused by ***Trichomonas vaginalis* (protozoa)** - Increases chances of cervical neoplasia, post op infections, pregnancy problems, PID and infertility - Risk factor: **IV drug use**r, incarceration, sex workers, **poor hygiene,** T1DM, multiple sexual partners - **Can be asymptomatic** - **KNOW S/sx**: thin, **yellow to yellow-green frothy copious & discharge, malodorous, burning,** and irritation - **KNOW Diagnosis**: **inspection with a speculum often reveals vaginal and cervical erythema with multiple small petechiae (strawberry spots),** pH greater than 4.5 - **Treatment: metronidazole or tinidazole PO once or PO TID for 1 week** - **KNOW No alcohol w/ metronidazole** - **No sex for 7-10 days** - Nursing care: - **Must treat sexual partners** - **Wear cotton underwear** - Determine probable cause - Educate patient of ways to prevent further infections based on cause - **Physical: NO bubble baths or douching** - **Psychogenic: stress, fear of STD** - Nursing dx: - Discomfort r/t burning odor and itching - Anxiety, Risk for infection, deficient knowledge about proper hygiene & preventative measures **Human Papillomavirus (HPV) (pg. 4480)** - Sexually transmitted, most common in young sexually active - Can be self-limiting w/ no s/sx while others cause cervical + anogenital cancer - **Latent period**: positive test for HPV followed negative HPV test which indicates pt had asymptomatic incident & was able to clear - **Subclinica**l: burning, dyspareunia, visible condylomata - **KNOW 6 and 11 cause condylomata/genital warts on the vulva** - **KNOW HPV 16 and 18 cause cervical cancer (accounts for 68% of cervical cancer)** - s/s: vaginal discomfort/pain, discharge, visible condylomata/warts \[if symptomatic\] - Risk Factors: sexually active, multiple partners, or a partner with multiple partners - **Spread during anal and vaginal sex most commonly BUT can be spread by skin to skin contact (lecture)** - Treatment - Most cases, goes away on its own but when it doesn't can cause genital warts and cancer (notes) - **KNOW At home, use podofilox or imiquimod applied by patient** - **KNOW External genital warts: trichloroacetic acid, podophyllin, or interferon administered by HCP** - Electrocautery or laser if they're pregnant - Nursing Care - **Important to stress about HPV vaccine:** - Both genders need to be vaccinated at 11 years old before being sexually active; they need to get a full course. - **Girls vaccinated (if not previously): 13-26** - **Males vaccinated (if not previously): 13-21** - Educate patient on application of topical medication and be able to identify warts - **Educate: may expect the genital warts to be a little painful and irritating (her notes) and make sure they know even if they get the gardasil vaccine, they will still need pap smears** - **Patient should have annual Pap smear even if vaccinated;** undetected can lead to dysplasia (changes in cervical cells) - Condoms help but do not prevent all transmission - Anxiety and Anger are common; provide support - Cancer: vulva, vagina, penis and anus and possibly back of the throat/base of the tongue and tonsils- can take years to manifest (HER notes, not sure if this is important) **Herpes Virus 2 (pg 4482)** - Recurrent, lifelong viral infection - STI: Can be transmitted asexually or by self-transmission - Can be transmitted even with condom use and when asymptomatic - Education: Initial infection very painful and may take 2-4 weeks to heal - Recurrent episodes milder than initial episode - **Symptoms**: **itchy lesions that may be open and bleed**, it is an infected area presents with itching and pain then macules/papules to vesicles to ulcer, blisters on the genitalia (sometimes vagina/cervix) - Influenza symptoms 3-4 days after lesions appear, Inguinal lymphadenopathy, fever, malaise, headache, Dysuria; **Lesions last 2-12 days before crusting over**, lesions can also bleed when open - Treatment: **No cure** - **KNOW Oral antiviral agents: acyclovir (Zovirax), valacyclovir (Valtrex), famciclovir (Famvir) can suppress s/s and shorten the course of infection** - **Patients may also use analgesics and saline compresses** - Education - **KNOW Initial episode is worse and the other espidoses are more mild** - This is because this is the first time that the immune system is encountering the virus for the first time and hasn\'t developed antibodies. - Medication, Preventing infection and spread of infection, Increasing Disease knowledge **Endocervicitis (pg 4488)** - Inflammation of the mucosa and the glands of the cervix that may occur when organisms gain access to the glands after intercourse and less often after a procedure - B/c they are ascending infections, if untreated, can travel up into the uterus, fallopian tubes, and pelvic cavity - **Causes: Chlamydia and Gonorrhea** (Mycoplasma may also be involved) **Chlamydia (pg. 4488) (MC STI)** - **Parasitics infection, NOT a bacteria** - S/sx: **usually asymptomatic** or cervical discharge, dyspareunia, dysuria, and bleeding may occur - Males can have urethritis, epididymitis, or proctitis **(primarily these pts will have testicular pain**) - Primary reservoir is male urethra - Females can get cervicitis w/ mucopurulent discharge, vaginitis, or **salpingitis** - Diagnosis: **urine culture or swab** - Issues it can cause: Pelvic infection, ectopic pregnancy, infertility, PID - **Pregnant**: stillbirth, neonatal death, premature labor - Babies born to infected moms: conjunctivitis, PNA - Conjunctivitis is why newborns get erythromycin - Cervicitis, urethritis, affects spleen bc of iliac lymph nodes - Treatment - **Doxycycline** PO for one week OR **Azithromycin** single dose - **Pregnant: erythromycin** (tetracycline contraindicated) - CDC recommends treating for gonorrhea since they are often found together using **cephalosporins such as cefixime (400mg PO x 1) or IM dose of ceftriaxone 250mg** - **KNOW Gonorrhea and chlamydia often occur together so tx is often used for both** - **Cultures retaken in 2 weeks after tx** - Follow up: - **All women aged 25 and younger who are sexually active should be screened annually. Those older than 25 years should be screening if risk factors are present** - Repeat testing should occur 3 months after tx begins **Nursing Management: Chlamydia/Gonorrhea** - **Discuss long term health effects (especially those around child bearing issues)** - **Can lead to PID which can increase the risk for ectopic pregnancies** - Assist patient with assessing own risk, Teach prevention - Educate about never assuming someone is "safe" - Reinforce the need for yearly screenings