NURS 3450 Module 1 CH 4 PDF

Chapter 4 Assessment & Health Promotion 1. Review figures 4.1, 4.2, & 4.3 on pages 48-49 of the Lowdermilk text and take notes as needed. Related review questions: a. What are the 3 layers of the uterus? The uterine wall is made up of three layers: the endometrium, the myometrium, and part of the pe...

Chapter 4 Assessment & Health Promotion 1. Review figures 4.1, 4.2, & 4.3 on pages 48-49 of the Lowdermilk text and take notes as needed. Related review questions: a. What are the 3 layers of the uterus? The uterine wall is made up of three layers: the endometrium, the myometrium, and part of the peritoneum. The endometrium is a highly vascular lining made up of three layers, the outer two of which are shed during menstruation. The myometrium is made up of layers of smooth muscles that extend in three different directions (longitudinal, transverse, and oblique) (Fig. 4.3). Longitudinal fibers of the outer myometrial layer are found mostly in the fundus, and this arrangement assists in expelling the fetus during the birth process. The middle layer contains fibers from all three directions, which form a figure-eight pattern encircling large blood vessels. These fibers assist in ligating blood vessels after birth and control blood loss. Most of the circular fibers of the inner myometrial layer are around the site where the uterine tubes enter the uterus and around the internal cervical os (opening). These fibers help keep the cervix closed during pregnancy and prevent menstrual blood from flowing back into the uterine tubes during menstruation. b. Describe the cervix – why type of tissue is present, what is the squamocolumnar junction? The uterine cervix projects into a blind vault at the upper end of the vagina. Anterior, posterior, and lateral pockets called fornices (singular: fornix) surround the cervix. The internal pelvic organs can be palpated through the thin walls of these fornices. The uterus is a muscular organ shaped like an upside-down pear that is positioned midline in the pelvic cavity between the bladder and rectum and above the vagina. Four pairs of ligaments support the uterus: cardinal, uterosacral, round, and broad. Single anterior and posterior ligaments also support the uterus. The cul-de-sac of Douglas is a deep pouch, or recess, posterior to the cervix formed by the posterior ligament. The uterus is divided into two major parts: an upper triangular portion called the corpus and a lower cylindric portion called the cervix (Fig. 4.2). The fundus is the dome-shaped top of the uterus and is the site at which the uterine tubes (fallopian tubes) enter the uterus. The isthmus, or lower uterine segment, is a short constricted portion that separates the corpus from the cervix. The squamocolumnar junction, where the two types of cells meet, is usually located just inside the cervical os. This junction is also called the transformation zone and is the most common site for neoplastic changes. Cells from this site are scraped for the Papanicolaou (Pap) test (see later discussion). 2. Parameters of the menstrual cycle – listen to the recorded review. Menstrual Cycle Menstruation is the periodic uterine bleeding that begins approximately 14 days after ovulation. It is controlled by a feedback system of three cycles: endometrial, hypothalamic-pituitary, and ovarian. The average length of a menstrual cycle is 28 days, but variations are normal. The first day of bleeding is designated as day 1 of the menstrual cycle, or menses (Fig. 4.7). The average duration of menstrual flow is 5 days (range of 3 to 6 days), and the average blood loss is 50 mL (range of 20 to 80 mL), but this duration of flow and blood loss vary greatly. a. Length in days: The average length of a menstrual cycle is 28 days b. Menstrual flow: days The average duration of menstrual flow is 5 days (range of 3 to 6 days) c. Blood loss in mL: the average blood loss is 50 mL (range of 20 to 80 mL), but this duration of flow and blood loss vary greatly. 3. Three cycles make up the menstrual cycle: Endometrial Cycle The four phases of the endometrial cycle are (1) the menstrual phase, (2) the proliferative phase, (3) the secretory phase, and (4) the ischemic phase (see Fig. 4.7). During the menstrual phase, shedding of the functional two-thirds of the endometrium (the compact and spongy layers) is initiated by periodic vasoconstriction in the upper layers of the endometrium. The basal layer is always retained, and regeneration begins near the end of the cycle from cells derived from the remaining glandular remnants or stromal cells in this layer. The proliferative phase is a period of rapid growth lasting from about the fifth day to the time of ovulation. The endometrial surface is completely restored in approximately 4 days, or slightly before bleeding ceases. From this point on, an 8- to 10-fold thickening occurs, with a leveling off of growth at ovulation. The proliferative phase depends on estrogen stimulation derived from ovarian follicles. The secretory phase extends from the day of ovulation to about 3 days before the next menstrual period. After ovulation, large amounts of progesterone are produced. An edematous, vascular, functional endometrium is now apparent. At the end of the secretory phase, the fully matured secretory endometrium reaches the thickness of heavy, soft velvet. It becomes luxuriant with blood and glandular secretions, creating a suitable protective and nutritive bed for a fertilized ovum. Implantation of the fertilized ovum generally occurs about 7 to 10 days after ovulation. If fertilization and implantation do not occur, the corpus luteum, which secretes estrogen and progesterone, regresses. With the rapid decrease in progesterone and estrogen levels, the spiral arteries go into spasm. During the ischemic phase, the blood supply to the functional endometrium is blocked and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins, marking day 1 of the next cycle (see Fig. 4.7). Hypothalamic-Pituitary Cycle The hypothalamus and anterior pituitary gland in females regulate the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). The target tissue for these hormones is the ovary, which produces ova and secretes estrogen and progesterone. A feedback mechanism between hormone secretion from the ovaries, the hypothalamus, and the anterior pituitary gland aids in the control of sex steroid hormone secretion. Toward the end of the normal menstrual cycle, blood levels of estrogen and progesterone decrease. Low blood levels of these ovarian hormones stimulate the hypothalamus to secrete gonadotropin-releasing hormone (GnRH). In turn, GnRH stimulates anterior pituitary secretion of FSH. FSH stimulates development of ovarian graafian follicles and their production of estrogen. Estrogen levels begin to decrease, and hypothalamic GnRH triggers the anterior pituitary to release LH. A marked surge of LH and a smaller peak of estrogen (day 12) (see Fig. 4.7) precede the expulsion of the ovum from the graafian follicle by about 24 to 36 hours. LH peaks at about day 13 or 14 of a 28-day cycle. If fertilization and implantation of the ovum have not occurred by this time, regression of the corpus luteum follows. Levels of progesterone and estrogen decline, menstruation occurs, and the hypothalamus is once again stimulated to secrete GnRH. This process is called the hypothalamic-pituitary cycle. Ovarian Cycle The primitive graafian follicles contain immature oocytes (primordial ova). Before ovulation, from 1 to 30 follicles begin to mature in each ovary under the influence of FSH and estrogen. The preovulatory surge of LH affects a selected follicle. The oocyte matures, ovulation occurs, and the empty follicle begins its transformation into the corpus luteum. This follicular phase (preovulatory phase) (see Fig. 4.7) of the ovarian cycle varies in length from woman to woman. Almost all variations in ovarian cycle length are the result of variations in the length of the follicular phase. On rare occasions (i.e., 1 in 100 menstrual cycles), more than one follicle is selected, and more than one oocyte matures and undergoes ovulation. After ovulation, estrogen levels decrease. For 90% of women, only a small amount of withdrawal bleeding occurs, and it goes unnoticed. In 10% of women, there is sufficient bleeding for it to be visible, resulting in what is termed midcycle bleeding. The luteal phase begins immediately after ovulation and ends with the start of menstruation. This postovulatory phase of the ovarian cycle usually requires 14 days (range of 13 to 15 days). The corpus luteum reaches its peak of functional activity 8 days after ovulation, secreting the steroids estrogen and progesterone. Coincident with this time of peak luteal functioning, the fertilized ovum is implanted in the endometrium. If no implantation occurs, the corpus luteum regresses and steroid levels decrease. Two weeks after ovulation, if fertilization and implantation do not occur, the functional layer of the uterine endometrium is shed through menstruation. 4. The endometrial cycle has 4 phases. List them below: a. Phase: The menstrual phase days 2 to 7 During the menstrual phase what happens? Shedding of the functional two-thirds of the endometrium (the compact and spongy layers) is initiated by periodic vasoconstriction in the upper layers of the endometrium. The basal layer is always retained, and regeneration begins near the end of the cycle from cells derived from the remaining glandular remnants or stromal cells in this layer. b. Phase: The proliferative phase days 1 to 14 Durinthe proliferative phaseg the phase, what happens? The proliferative phase is a period of rapid growth lasting from about the fifth day to the time of ovulation. The endometrial surface is completely restored in approximately 4 days, or slightly before bleeding ceases. From this point on, an 8- to 10-fold thickening occurs, with a leveling off of growth at ovulation. The proliferative phase depends on estrogen stimulation derived from ovarian follicles. c. Phase: The secretory phase days 14 to 28 During the phase, what happens? The secretory phase extends from the day of ovulation to about 3 days before the next menstrual period. After ovulation, large amounts of progesterone are produced. An edematous, vascular, functional endometrium is now apparent. At the end of the secretory phase, the fully matured secretory endometrium reaches the thickness of heavy, soft velvet. It becomes luxuriant with blood and glandular secretions, creating a suitable protective and nutritive bed for a fertilized ovum. d. Phase: The ischemic phase day 28 During the phase, what happens? During the ischemic phase, the blood supply to the functional endometrium is blocked and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins, marking day 1 of the next cycle 5. The ovarian cycle has 2 phases: Phase: follicular days 1 to 14 During the phase, what happens? The primitive graafian follicles contain immature oocytes (primordial ova). Before ovulation, from 1 to 30 follicles begin to mature in each ovary under the influence of FSH and estrogen. The preovulatory surge of LH affects a selected follicle. The oocyte matures, ovulation occurs, and the empty follicle begins its transformation into the corpus luteum. This follicular phase (preovulatory phase) (see Fig. 4.7) of the ovarian cycle varies in length from woman to woman. Almost all variations in ovarian cycle length are the result of variations in the length of the follicular phase. On rare occasions (i.e., 1 in 100 menstrual cycles), more than one follicle is selected, and more than one oocyte matures and undergoes ovulation. After ovulation, estrogen levels decrease. For 90% of women, only a small amount of withdrawal bleeding occurs, and it goes unnoticed. In 10% of women, there is sufficient bleeding for it to be visible, resulting in what is termed midcycle bleeding. Phase: luteal days immediately after ovulation ( day 15 of 28 day cycle) and ends with the start of menstruation. During the phase, what happens? The luteal phase begins immediately after ovulation and ends with the start of menstruation. This postovulatory phase of the ovarian cycle usually requires 14 days (range of 13 to 15 days). The corpus luteum reaches its peak of functional activity 8 days after ovulation, secreting the steroids estrogen and progesterone. Coincident with this time of peak luteal functioning, the fertilized ovum is implanted in the endometrium. If no implantation occurs, the corpus luteum regresses and steroid levels decrease. Two weeks after ovulation, if fertilization and implantation do not occur, the functional layer of the uterine endometrium is shed through menstruation. 6. The hypothalamic-pituitary cycle has 2 phases: Phase: follicle-stimulating hormone days 6 to day 14 During the phase, what happens? Toward the end of the normal menstrual cycle, blood levels of estrogen and progesterone decrease. Low blood levels of these ovarian hormones stimulate the hypothalamus to secrete gonadotropin-releasing hormone (GnRH). In turn, GnRH stimulates anterior pituitary secretion of FSH. FSH stimulates development of ovarian graafian follicles and their production of estrogen. a. Phase: luteinizing hormone days begins after ovulation (day 13) ends just before a (day 28) menstrual period. During the phase, what happens? Estrogen levels begin to decrease, and hypothalamic GnRH triggers the anterior pituitary to release LH. A marked surge of LH and a smaller peak of estrogen (day 12) (see Fig. 4.7) precede the expulsion of the ovum from the graafian follicle by about 24 to 36 hours. LH peaks at about day 13 or 14 of a 28-day cycle. If fertilization and implantation of the ovum have not occurred by this time, regression of the corpus luteum follows. Levels of progesterone and estrogen decline, menstruation occurs, and the hypothalamus is once again stimulated to secrete GnRH. This process is called the hypothalamic-pituitary cycle. 7. What are some signs & symptoms of ovulation? Breast Tenderness, Increased sex drive, Mucus, Change in basal body temp., Spotting, Cervix Position, Temperature Changes, Bloating, Ovulation pain. 8. Describe the function of the following hormones in the menstrual cycle: a. Estrogen → Initially, menstrual periods are irregular and unpredictable and anovulatory (no ovum is released from the ovary). After 1 or more years, a hypothalamic-pituitary rhythm develops and the ovary produces adequate cyclic estrogen to make a mature ovum. Ovulatory (ovum released from the ovary) periods tend to be regular, with estrogen dominating the first half of the cycle and progesterone dominating the second half. b. Progesterone → The secretory phase extends from the day of ovulation to about 3 days before the next menstrual period. After ovulation, large amounts of progesterone are produced. An edematous, vascular, functional endometrium is now apparent. At the end of the secretory phase, the fully matured secretory endometrium reaches the thickness of heavy, soft velvet. It becomes luxuriant with blood and glandular secretions, creating a suitable protective and nutritive bed for a fertilized ovum. Implantation of the fertilized ovum generally occurs about 7 to 10 days after ovulation. If fertilization and implantation do not occur, the corpus luteum, which secretes estrogen and progesterone, regresses. With the rapid decrease in progesterone and estrogen levels, the spiral arteries go into spasm. During the ischemic phase, the blood supply to the functional endometrium is blocked and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins, marking day 1 of the next cycle (see Fig. 4.7). Prostaglandins → Prostaglandins (PGs) are oxygenated fatty acids classified as hormones. The different kinds of PGs are distinguished by letters (PGE and PGF), numbers (PGE2), and letters of the Greek alphabet (PGF2α). PGs are produced in most organs of the body including the uterus. Menstrual blood is a potent PG source. PGs are metabolized quickly by most tissues. They are biologically active in minute amounts in the cardiovascular, gastrointestinal, respiratory, urogenital, and nervous systems. They also exert a marked effect on metabolism, particularly on glycolysis. PGs play an important role in many physiologic, pathologic, and pharmacologic reactions. PGF2α, PGE4, and PGE2 are most commonly used in reproductive medicine. PGs affect smooth muscle contractility and modulation of hormonal activity. Indirect evidence indicates that PGs have an effect on ovulation, fertility, changes in the cervix, and cervical mucus that affect receptivity to sperm, tubal and uterine motility, sloughing of endometrium (menstruation), onset of miscarriage and induced abortion, and onset of labor (term and preterm). After exerting biologic actions, newly synthesized PGs are rapidly metabolized by tissues in organs such as the lungs, kidneys, and liver. PGs may play a key role in ovulation. If PG levels do not rise along with the surge of LH, the ovum remains trapped within the graafian follicle. After ovulation, PGs may influence production of estrogen and progesterone by the corpus luteum. The introduction of PGs into the vagina or the uterine cavity (from ejaculated semen) increases the motility of uterine musculature, which may assist the transport of sperm through the uterus and into the oviduct. PGs produced by a woman cause regression of the corpus luteum and regression and sloughing of the endometrium, resulting in menstruation. PGs increase myometrial response to oxytocic stimulation, enhance uterine contractions, and cause cervical dilation. They may be a factor in the initiation of labor, the maintenance of labor, or both. They may also be involved in dysmenorrhea (see Chapter 6) and preeclampsia/eclampsia (see Chapter 27). Follicle stimulating hormone (FSH) Practice Question Chapter 4 1. It is day 17 of a woman’s menstrual cycle. She is complaining of breast tenderness and pain in her lower left a. b. c. d. quadrant. The woman states her cycle is usually 31 days long. Which of the following is an appropriate response by the nurse? You are probably ovulating. Your hormone levels should be checked. You will probably menstruate early. Your breast changes are a worrisome sign. Bottleneck or Difficult Concepts In your Elsevier Sherpath resource, there are case studies, further Sherpath lessons, and chapter PowerPoint sets for your review. Take notes as needed.