NURS 3450 Module 2 CH 7 PDF

NURS 3450 Maternity and Women’s Health Nursing Comfort Measures for Menopausal Symptoms Hot Flashes/Flushes During the Day Wear layered clothing that “wicks” so you can take things off if you get warm. Avoid “triggers” that bring on a flash/flush; these include vigorous exercise on hot days, spi...

NURS 3450 Maternity and Women’s Health Nursing Comfort Measures for Menopausal Symptoms Hot Flashes/Flushes During the Day Wear layered clothing that “wicks” so you can take things off if you get warm. Avoid “triggers” that bring on a flash/flush; these include vigorous exercise on hot days, spicy foods, red wine, caffeine, hot beverages, and alcohol. Splash your face with cool water, drink ice water, or take a cool shower. Try slow, deep breathing. At Night Sleep in cotton night clothes, use cotton sheets, keep the room cool, and possibly sleep with a fan on. Avoid heavy blankets that will make you too warm at night. Keep a glass of water by the bed. Avoid using electronic devices (smart phones, computers, other screens) for 30 minutes before bedtime. Chapter 7 Sexually Transmitted and Other Infections 1. What are the 6 Ps that should be assessed regarding STIs (see box 7.2)? 1.Partners 2.Practices 3.Prevention of Pregnancy 4.Protection from STIs 5.Past history of STIs 6.Pregnancy Plans BOX 7.2 Five Ps Approach for Health Care Providers Obtaining Sexual Histories 1.Partners Are you currently having sex of any kind? What is the gender(s) of your partner(s)? 2.Practices To understand your risks for STIs, I need to ask more specific questions about the kind of sex you have had recently. What kind of sexual contact do you have, or have you had? Do you have vaginal sex, meaning “penis in vagina” sex? Do you have anal sex, meaning “penis in rectum/anus” sex? Do you have oral sex, meaning “mouth on penis/vagina” sex? 3.Protection from STIs Do you and your partner(s) discuss prevention of STIs and HIV? Do you and your partner(s) discuss getting tested? Additional question regarding condom use: What protection methods do you use? In what situations do you use condoms? 4Past history of STIs Have you ever been tested for STIs and HIV? NURS 3450 Maternity and Women’s Health Nursing Have you ever been diagnosed with an STI in the past? Have any of your partners had an STI? Additional questions for identifying HIV and viral hepatitis risk: Have you or your partner(s) ever injected drugs? Is there anything about your sexual health that you have questions about? 5Pregnancy intention Do you think you would like to have (more) children in the future? How important is it to you to prevent pregnancy (until then)? Are you and your partner(s) using contraception or practicing any form of birth control? Would you like to talk about ways to prevent pregnancy? NURS 3450 Maternity and Women’s Health Nursing 2. To guide your learning about common STIs and other vaginal infections, complete the following table. STI Signs/symptoms Chlamydia Abnormal Discharge. Burning Sensation During Urination. Gonorrhea Women → Asymptomatic. Menstrul Irregularities. How diagnosed/treatment/prevented For diagnosis of chlamydia in women, the CDC recommends the nucleic acid amplification test (NAAT) using urinary, vaginal, or endocervical specimens (CDC, 2021a). The NAAT is the most sensitive test for these specimens and has been cleared by the US Food and Drug Administration (FDA) for client self-collected or clinician-collected vaginal swabs in a clinical setting. An NAAT is also recommended by the CDC for rectal and oropharyngeal screening among persons engaging in receptive anal or oral intercourse. The CDC recommendations for treatment of urethral, cervical, and rectal chlamydial infections are azithromycin, levofloxacin, or doxycycline (CDC, 2021a). Azithromycin is often prescribed when compliance may be a problem because only one dose is needed. If the woman is pregnant, azithromycin or amoxicillin is used. Pregnant women should be retested in approximately 4 weeks to determine if treatment was effective (test of cure). In addition, all pregnant women who have a chlamydial infection should be retested 3 months after treatment (CDC). Women who have a chlamydial infection and are also infected with HIV should be treated with the same regimen as clients who are not infected with HIV. Patient education Because chlamydia is often asymptomatic, the woman should be cautioned to take all medication prescribed. All exposed sexual partners should also be treated. Nonpregnant women treated with doxycycline or azithromycin do not have to be retested unless symptoms continue, adherence was in question, or reinfection is suspected. Specific diagnosis of infection with N. gonorrhoeae can be obtained by testing an endocervical, vaginal, rectal, oropharyngeal, or conjunctival Gonorrhea is a highly communicable disease, and to NURS 3450 Maternity and Women’s Health Nursing Pelvic/lower abdominal pain. Longer menses. gonococcal infection or urinary specimens. Culture and nonculture tests (nucleic acid hybridization tests and NAATs) are available for the detection of N. gonorrhoeae. NAATs and point-of-care (POC) NAATs allow for the widest array of FDA-cleared specimen types including endocervical and vaginal swabs (can be clinician or client collected), urine swabs, and pharyngeal swabs (CDC, 2021a). NAAT sensitivity for detecting N. gonorrhea from urogenital and nongenital anatomic sites is superior to culture but varies by NAAT type, and the CDC recommends that product inserts for each NAAT manufacturer be consulted. Management of a client with gonorrhea is straightforward; with appropriate antibiotic therapy, the cure is usually rapid. Single-dose efficacy is a major consideration in selecting an antibiotic regimen for women with gonorrhea. Previously the CDC recommended a dual therapy for gonorrhea, but this has been found to have potential harm and thus no longer is a treatment recommendation (CDC, 2021a). Now the treatment of choice for uncomplicated urethral, endocervical, and rectal infections in pregnant and nonpregnant women is ceftriaxone (an injectable cephalosporin); this is now the only CDC-recommended treatment regimen for gonorrhea (CDC). Another important consideration is the high percentage of women with coexisting chlamydial infections. If a chlamydial infection is suspected and has not been ruled out, the recommendation is to treat with doxycycline in addition to ceftriaxone. Pregnant women should be treated with ceftriaxone plus treatment for chlamydia if suspected reduce complications and transmission, it is recommended that medication be given at the visit and that it be directly observed (directly observed therapy [DOT]) (CDC, 2021). It is important to notify partners if a woman is diagnosed with a gonorrheal infection. Recent (past 30 days) sexual partners should be examined and treated with appropriate regimens if positive for gonorrhea. Most treatment failures result from reinfection. The woman must be informed of this as well as of the consequences of reinfection in terms of chronicity, complications, and potential infertility. To address disease NURS 3450 Maternity and Women’s Health Nursing and not ruled out. Gentamicin use during pregnancy is cautioned because of risk of teratogenic effects, nephrotoxicity, or ototoxicity. Women who are not able to follow the treatment guidelines because of allergy or other conditions should be referred to an infectious disease specialist or an STI clinical expert for management (CDC). Women with HIV should receive the same treatment regimen as women who do not have HIV. Syphilis (including stages) Primary → During the first (primary) stage of syphilis, you may notice a single sore or Diagnosis depends on microscopic examination of primary and secondary lesion tissue and serology during latency and late infection. Dark-field examinations and tests to detect T. pallidum directly from lesion transmission, women are counseled to use condoms with sexual intercourse to prevent future STIs. They should be instructed to abstain from all sexual activity during treatment and for 7 days after treatment. Abstention from sexual activity is also recommended to continue for 7 days after all sexual partners have been treated. All clients with gonorrhea should be offered confidential counseling and testing for other STIs including chlamydia, syphilis, and HIV infection. Clients who are negative for HIV should be offered HIV PrEP (CDC). Penicillin G is the preferred drug for treating syphilis. It is the only proven NURS 3450 Maternity and Women’s Health Nursing multiple sores. The sore is the location where syphilis entered your body. Secondary → During the secondary stage, you may have skin rashes and/or sores in your mouth, vagina, or anus. This stage usually starts with a rash on one or more areas of your body. The rash can show up when your primary sore is healing or several weeks after the sore has healed. The rash can be on the palms of your hands and/or the bottoms of your feet and look. Latent → The latent stage of syphilis is a period when there are no visible signs or symptoms. Without treatment, you can continue to have syphilis in your body for years. Tertiary → Most people with untreated syphilis do not develop tertiary syphilis. However, when it does happen, it can affect many different organ systems. These exudate or tissue are the definitive methods for diagnosing early syphilis. A test for antibodies may not be reactive in the presence of active infection because it takes time for the immune system to develop antibodies to any antigen. Up to onethird of people with early primary syphilis may have nonreactive serologic tests. Two types of serologic tests are used: nontreponemal and treponemal. Nontreponemal antibody tests, such as the Venereal Disease Research Laboratories (VDRL) or the rapid plasma reagin (RPR) test, are used as screening tests. Falsepositive results are not unusual, particularly when acute infection, autoimmune disorders, malignancy, pregnancy, and substance use disorder exist and after immunization or vaccination. The treponemal tests —fluorescent treponemal antibodyabsorption (FTA-ABS) test and T. pallidum particle agglutination (TPPA) assay—are used to confirm positive results. Test results in clients with early primary or incubating syphilis can be negative. Seroconversion usually takes place 6 to 8 weeks after exposure, so testing should be repeated in 1 to 2 months when a suggestive genital lesion exists. Tests for coexisting STIs (e.g., chlamydia and gonorrhea) should be done (e.g., NAATs and cultures), and HIV testing should be offered if indicated (CDC, 2021a). therapy that has been widely used to treat neurosyphilis, congenital syphilis, or syphilis during pregnancy. Intramuscular benzathine penicillin G is used to treat primary, secondary, and early latent syphilis. Although doxycycline and tetracycline are alternative treatments for penicillinallergic clients, both are contraindicated in pregnancy. Therefore pregnant women should, if necessary, receive skin testing and be treated with penicillin or be desensitized (CDC, 2021a). Specific protocols are recommended in the CDC STI treatment guidelines (https://www.c dc.gov/std/trea tmentguidelines/STI- NURS 3450 Maternity and Women’s Health Nursing Guidelines2021.pdf). include the heart and blood vessels, and the brain and nervous system. Tertiary syphilis is very serious and would occur 10–30 years after your infection began. In tertiary syphilis, the disease damages your internal organs and can result in death. A healthcare provider can usually diagnose tertiary syphilis with the help of multiple tests. HIV Most people have flu-like symptoms within 2 to 4 weeks after infection. Symptoms may last for a few days or several weeks. HIV infection is usually diagnosed by using HIV-1 and HIV-2 antigen/antibody combination tests. Antibody testing is first done with a sensitive screening test such as the enzyme immunoassay (EIA). Reactive screening tests should be confirmed using RNA testing (CDC, 2021). If a positive antibody test is confirmed by a supplemental test, it means that a woman is infected with HIV and is capable of infecting others. HIV antibodies are detectable in at least 95% of individuals within 3 months after infection. Although a negative antibody test usually indicates that a person is not infected, antibody tests cannot exclude recent infection. The FDA has approved six rapid HIV antibody screening tests for clinical use. These tests use a blood sample obtained by fingerstick or venipuncture, an oral fluid sample, or a urine sample to provide test results within 20 minutes. The tests have sensitivity and specificity rates of greater than 99%. If the results are While test results are being provided to an HIVpositive woman, privacy with no interruptions is essential. Adequate time for the counseling session is provided. The nurse makes sure that the woman understands what a positive test means and reviews its reliability. Riskreduction practices are reemphasized. Referral for appropriate NURS 3450 Maternity and Women’s Health Nursing reactive, further testing is necessary (CDC). Quicker results mean that clients do not have to make extra visits for follow-up standard tests, and the oral test provides an option for clients who do not want to have a blood test. medical evaluation and follow-up is made, and the need or desire for psychosocial or psychiatric referrals is assessed. It is important to stress early medical evaluation so that a baseline assessment can be made and prophylactic medication begun. Highly effective antiretroviral therapy (ART) suppresses HIV replication to undetectable levels, reduces morbidity, provides a near-normal lifespan, and prevents sexual transmission of HIV to others. The CDC recommends that women with HIV infection be offered ART as soon as possible and linked to care with a HIV/communic able disease specialist (CDC, NURS 3450 Maternity and Women’s Health Nursing HSV I & II characterized by multiple painful lesions, fever, chills, malaise, and severe dysuria and may last 2 to 3 weeks. Women generally have a more severe clinical course than men. Women with primary genital herpes have many lesions that progress from macules to papules and then form vesicles, pustules, and ulcers that crust and heal without scarring (Fig. 7.3). These ulcers are extremely tender, and primary infections may be bilateral. Women can also have itching, inguinal tenderness, and lymphadenopathy. Severe vulvar edema may develop, and women may have difficulty sitting. HSV cervicitis is also common with initial HSV-2 infections. The cervix may appear normal or be friable, reddened, ulcerated, or necrotic. A heavy watery-to-purulent vaginal discharge is common. Extragenital lesions may be present because of autoinoculation. A viral culture and HSV antigen detection by polymerase chain reaction (PCR) are obtained by swabbing exudate during the vesicular stage of the disease. For clients with a clinical history of HSV but who do not have active lesions or whose lesions have a negative culture or PCR result, type-specific serologic tests detecting HSV-1 and HSV-2 antibodies are available and may be useful in the clinical setting (ACOG, 2020). 2021). Counseling and education are critical components of the nursing care of women with herpes infections. Information regarding the etiology, signs and symptoms, transmission, and treatment should be provided. The nurse explains that each woman is unique in her response to herpes and emphasizes the variability of symptoms. Women are helped to understand when viral shedding and transmission to a partner are most likely. They should be counseled to refrain from sexual contact from the onset of the prodrome until the lesions have completely healed. Suppressive therapy may be an option NURS 3450 Maternity and Women’s Health Nursing Urinary retention and dysuria may occur secondary to autonomic involvement of the sacral nerve root. because it can decrease the risk of transmission to partners. HSV increases the risk of acquiring HIV by approximately twofold to fourfold owing to the open ulcers or breaks in the skin caused by the virus (CDC, 2022d). Some authorities recommend consistent use of condoms for all persons with genital herpes. Condoms may not prevent transmission, particularly male-to-female transmission; however, this does not mean that the partners should avoid all intimacy. Women can maintain close contact with their partners who are aware of the need to avoid contact with the woman’s herpetic lesions. The NURS 3450 Maternity and Women’s Health Nursing nurse explains that when lesions are active, it is important to avoid sharing intimate articles such as washcloths that touch the lesions. Plain soap and water or hand sanitizer can be used to clean hands that have come into contact with herpetic lesions; isolation is neither necessary nor appropriate. Because neonatal HSV infection has serious effects, prevention is critical. Recommendati ons include carefully examining and questioning all women about symptoms of HSV infection at the onset of labor. If visible lesions are not present at onset of labor, vaginal birth is acceptable. Cesarean birth is NURS 3450 Maternity and Women’s Health Nursing recommended if visible lesions are present (ACOG, 2020). Some authorities also recommend cesarean birth if prodromal symptoms (such as genital tingling) are present, even if there are no visible lesions. Infants who are born through an infected vagina should be carefully observed, and their body fluids should be cultured (see Chapter 35). The emotional effect of contracting an incurable STI such as herpes is considerable. At diagnosis, many emotions may surface— helplessness, anger, denial, guilt, anxiety, shame, or inadequacy. Women need the opportunity to discuss their feelings and need help in learning to live with the disease. Herpes NURS 3450 Maternity and Women’s Health Nursing Hep. A HAV infection is characterized by flulike symptoms, with malaise, fatigue, anorexia, nausea, pruritus, fever, and right upper quadrant pain. Serologic testing to detect the immunoglobulin M (IgM) antibody is done to confirm acute infections. The IgM antibody is detectable 5 to 10 days after exposure and can remain positive for up to 6 months. Because HAV infection is self-limited and does not result in chronic infection or chronic liver disease, treatment is usually supportive. Women who become dehydrated from nausea and vomiting or who have signs or symptoms of acute liver failure may need to be hospitalized. Medications and other ingested substances that might cause liver damage or are metabolized in the liver (e.g., acetaminophen, ethyl alcohol) should be avoided. No specific diet or activity restrictions are necessary. HAV vaccine and immunoglobulin for intramuscular administration are effective in preventing most HAV infections (CDC). Food-related hepatitis A outbreaks are reportable, and local health departments and the CDC are involved in locating the source of infection and as many infected individuals as possible. can affect a woman’s sexuality, her sexual practices, and her current and future relationships. Women may need help in raising the issue with their partners or future partners. The partners may also benefit from counseling. Vaccination is the most effective preventive measure in mitigating the transmission of HAV among persons at risk for infections (CDC, 2021). In the United States, two monovalent vaccines are approved by the FDA for individuals >12 months of age; both are administered intramuscularly (IM) in a twodose series. A combined HAV and hepatitis B virus (HBV) vaccine has been approved and used as a NURS 3450 Maternity and Women’s Health Nursing Hep. B Symptoms of HBV infection are similar to those of HAV infection: arthralgias, arthritis, lassitude, anorexia, nausea, vomiting, headache, fever, and mild abdominal pain. Later the woman may have claycolored stools, dark urine, increased abdominal pain, and jaundice. Some individuals with HBV have persistence of HBsAg and become chronic HBV carriers. All women at high risk for contracting HBV should be screened regularly at routine appointments. Clients who are found to be HBV-positive should be tested for HIV, syphilis, gonorrhea, and chlamydia (CDC, 2021). Screening for the presence of HBsAg is recommended for all pregnant women at the first prenatal visit regardless of whether they have been tested previously and again at birth if the woman is at high risk for HBV infection (CDC). If HBsAg persists in the blood, the woman is identified as having chronic HBV infection (CDC, 2021). If the HBsAg test result is positive, further laboratory studies may be ordered: anti-HBe, anti-HBc, serum glutamicoxaloacetic transaminase (SGOT), alkaline phosphatase, and a liver panel. three-dose series for adults >18 years of age and at risk for either HAV or hepatitis B virus (HBV) infection (CDC). Client education includes explaining the meaning of HBV infection and describing transmission, state of infectivity, and sequelae. The nurse explains the need for monoprophylax is for household members and sexual contacts. To decrease transmission of the virus, women with acute or chronic hepatitis B should be advised to maintain a high level of personal hygiene (e.g., wash hands after using the toilet; carefully dispose of tampons, pads, and bandages in plastic bags; do not share NURS 3450 Maternity and Women’s Health Nursing HPV HPV lesions in women are most commonly seen in the posterior part of the introitus; however, lesions are also found on the buttocks, vulva, vagina, anus, and cervix (Fig. 7.2). Viral screening and typing for HPV is available but not standard practice for women younger than 30 years of age. History, evaluation of signs and symptoms, and physical examination are used in making a diagnosis of anogenital warts caused by HPV. The only definitive diagnostic test for the presence of HPV is histologic evaluation of a biopsy specimen. razor blades, toothbrushes, needles, or manicure implements; have male partner use a condom if unvaccinated and without hepatitis; and wipe up blood spills immediately with soap and water). Women with hepatitis B should inform all health care providers of their carrier state. Postpartum women can be reassured that breastfeeding is not contraindicated if their infants received prophylaxis at birth and are currently on the recommended immunization schedule (see Chapter 24). Client counseling is essential to reduce the prevalence of HPV and to improve the management of HPV in women who are NURS 3450 Maternity and Women’s Health Nursing Typically the lesions are small—2 to 3 mm in diameter and 10 to 15 mm in height. They appear as soft, papillary swellings occurring singly or in clusters in the genital and anorectal regions. Lesions resulting from infections of long duration may appear as a cauliflower-like mass. In moist areas such as the vaginal introitus, the lesions may appear to have multiple, fine fingerlike projections. Vaginal lesions are often multiple. Flattopped papules, 1 to 4 mm in diameter, are seen most often on the cervix and are often visualized only under magnification. Warts are usually flesh-colored or slightly darker based on skin tones. The lesions are often painless but may be uncomfortable, particularly when they are very large, inflamed, or ulcerated. Chronic vaginal discharge, pruritus, or dyspareunia can occur. Primary high-risk human papillomavirus (hrHPV) testing can be used in combination with the Papanicolaou (Pap) test to screen for types of HPV that are associated with cervical cancer in women older than age 30 or in women with abnormal Pap test results (ACOG, 2021). In 2020 the American Cancer Society (ACS) revised its guidelines on screening for cervical cancer with hrHPV testing for women 25 to 65 years of age at average risk. At the current time, two hrHPV tests are approved by the FDA (ACOG). In 2021 ACOG, the American Society for Colposcopy and Cervical Pathology (ASCCP), and the Society for Gynecologic Oncology (SGO) endorsed the USPSTF in their recommendations for routine cervical cancer screening (ACOG). These recommendations expand the options for cervical cancer screening in average-risk women age 30 years and older to include screening every 5 years with primary hrHPV testing. The ACS is strongly advocating for the phasing out of cytology-based options and moving to hrHPV testing as the preferred screening option for average-risk women aged 25 to 65 years (Fontham, Wolf, Church, et al., 2020). Based on several barriers such as limited access in rural and underresourced communities and communities of color, limited availability of FDA-approved tests, and laboratory restrictions with this screening modality, ACOG supports the continued use of cytology-based screening options in the current guidelines. However, ACOG acknowledges that future screening recommendations such as raising the age of screening initiation to 25 years as supported by ACS may be a viable infected. Women need to know that HPV infection is very common and will clear up spontaneously in most cases. Some infections will progress to genital warts, precancerous lesions, or cancers. Women must understand how the virus is transmitted, that no immunity is conferred with infection, and that reacquisition of the infection is likely with repeated contact. It is important to counsel the woman that when she acquired HPV cannot be definitively determined, as genital warts can develop months or years after acquiring the virus. Because HPV is highly contagious, many partners of women with NURS 3450 Maternity and Women’s Health Nursing consideration as more data become available (ACOG). HPV are infected even if they are asymptomatic. All sexually active women with multiple partners or a history of HPV should be encouraged to use latex condoms consistently and correctly for intercourse to decrease the risk of acquisition or transmission of genital HPV (CDC, 2021d). Instructions for all medications and treatments must be detailed. Women should be told that treatments are for the conditions caused by the virus but not for HPV itself. Women should be informed before treatment of the possibility of posttreatment pain associated with specific therapies. The importance of the thorough NURS 3450 Maternity and Women’s Health Nursing treatment of concurrent vaginitis or a coexisting STI should be emphasized. The link between cervical cancer and some HPV infections (such as HPV 16 and 18) and the need for close follow-up should be discussed. Annual health examinations are recommended to assess disease recurrence and screen for cervical cancer at the recommended intervals based on age, test used, and past confirmed diagnosis of a cervical dysplasia or neoplasm. Women 21 years of age and older should be counseled to have regular Pap testing, as recommended for women without genital warts; they do not need Pap NURS 3450 Maternity and Women’s Health Nursing tests more frequently than the recommendati ons (CDC, 2021). Women must be counseled on the importance of stopping tobacco use and of smoking cessation programs because of the contribution of smoking to the progression of precancer and cancer due to oncogenic HPV persistence. They need to understand that the types of HPV that cause genital warts are different from the types that can cause cancer (CDC). Preventive strategies such as those presented in the following section should be discussed. Preventive strategies include abstinence from all sexual activity (most reliable method for preventing NURS 3450 Maternity and Women’s Health Nursing genital HPV infection), staying in a long-term monogamous relationship, limiting the number of sexual partners, and prophylactic vaccination (CDC, 2021). Gardasil 9, a nine-valent vaccine, is the only available vaccine in the United States (Meites, Szilagvi, Chesson, et al., 2019). This vaccine was initially recommended for females 9 to 26 years old and then became available to males. In 2019 the FDA added an indication for women and men 27 to 45 years old based on shared clinical decision making with their healthcare provider (Thompson, Garz, Galvin, et al., 2021). The vaccine is safe and effective in NURS 3450 Maternity and Women’s Health Nursing protecting against some of the most common types of HPV that can lead to genital warts and cancers. Gardasil 9 protects against HPV types 6, 11, 16, 18, 31, 33, 35, 45, 52, and 58. The vaccine is most effective if given before the first sexual contact (Meites et al., 2019). The vaccine can be given to girls and boys as early as 9 years of age and can be given to females and males 15 to 26 years old if they have not received the vaccine previously. The vaccine is given in a two-dose schedule for girls and boys who initiate the vaccine series at ages 9 to 14 years. The three-dose schedule is for individuals who are immunocompr omised or initiate the NURS 3450 Maternity and Women’s Health Nursing vaccine series at ages 15 to 26 years and individuals 27 to 45 years old. Trichomoniasis Although trichomoniasis may be asymptomatic, commonly women have a characteristic yellowish to greenish discharge that is frothy, mucopurulent, copious, and malodorous. Inflammation of the vulva, vagina, or both may be present, and the woman may experience irritation and pruritus. Dysuria and dyspareunia are often present. Typically the discharge worsens during and after menstruation. Often the cervix and vaginal walls will demonstrate the characteristic “strawberry spots” or tiny petechiae, and the cervix may bleed on contact. In severe infections, the vaginal walls, the cervix, and occasionally the vulva may be acutely inflamed. The use of highly sensitive and specific tests is recommended for detecting T. vaginalis. NAAT is highly sensitive in women, often detecting three to five times more T. vaginalis infections than wet-mount microscopy, a method with poor sensitivity (44% to 68%). Reliable samples for testing are cliniciancollected endocervical swabs, clinician-collected vaginal swabs, urine samples, and liquid Pap specimens collected in PreservCyt Solution. Vaginal swab and urine have up to 100% concordance in women. Clinicians using wet mounts should attempt to evaluate slides immediately because sensitivity declines as evaluation is delayed, decreasing by up to 20% within 1 hour after collection (CDC, 2021). Because trichomoniasis is an STI, once diagnosis has been confirmed, appropriate laboratory studies for other STIs should be carried out. The recommended treatment is metronidazole orally twice per day for 7 days or tinidazole orally in a single dose (CDC, 2021). Although the male partner is usually asymptomatic, it is recommended that he receive treatment also because he often harbors the trichomonads in the urethra or prostate. It is important that nurses discuss the significance of partner treatment with their clients because if the partners are not treated it is likely that the infection will recur. Nurses also counsel women to abstain from sex until they and their partners have been treated Women with trichomoniasis must understand the sexual transmission of this disease. They must know that the organism may be present without any associated symptoms, perhaps for several months, and that it is not possible to determine when they became infected. Women are informed of the necessity for treating all sexual partners and helped with ways of raising this issue with them. NURS 3450 Maternity and Women’s Health Nursing (i.e., when therapy has been completed and any symptoms have resolved). Bacterial vaginosis It is a syndrome in which normal hydrogen peroxide (H2O2)–producing lactobacilli are replaced with high concentrations of anaerobic bacteria (Gardnerella and Mobiluncus). With the increased number of anaerobes, the level of vaginal amines is increased, and the normal acidic pH of the vagina is altered. Epithelial cells slough, and numerous bacteria attach to their surfaces (clue cells). The odor may be noticed by the woman or her partner after heterosexual intercourse because semen releases the vaginal amines. When present, the BV discharge usually appears profuse, thin, and white, gray, or milky. Some women may also experience mild irritation or pruritus. Microscopic examination of vaginal secretions is always performed (Table 7.2). Both normal saline and 10% potassium hydroxide (KOH) smears are made. The presence of more than 20% clue cells (vaginal epithelial cells coated with bacteria) on a wet saline smear is highly diagnostic because the phenomenon is specific to BV. Vaginal secretions are tested for pH and amine odor. Nitrazine paper is sensitive enough to detect a pH of 4.5 or greater. The fishy odor of BV will be released when KOH is added to vaginal secretions on the lip of the withdrawn speculum (CDC, 2021). Treatment of BV with oral or gel metronidazole (Flagyl) and clindamycin cream is equally effective. The side effects of metronidazole are numerous, including an unpleasant metallic taste in the mouth, headache, dizziness, weakness, a swollen or “furry” tongue, and gastrointestinal symptoms. In the past, women were counseled to not consume alcohol while taking metronidazole, but the CDC found no data to support this practice and it was removed from their 2021 STI Treatment Guidelines (CDC, 2021). The treatment of sexual partners is not routinely recommended; however, women should be counseled to abstain from sexual activity or to use condoms correctly and consistently during the treatment timeframe. Douching might increase the risk of a relapse, and there are no data to support the use of douching for treatment or symptom relief (CDC, 2021). Medication Alert Metronidazole is not recommended if the woman is breastfeeding. However, if it is necessary to prescribe it, the woman can suspend breastfeeding (pump and discard to maintain milk supply) during treatment and for 12 to 24 hours after the last dose to reduce the infant’s exposure to metronidazole (CDC, 2021). NURS 3450 Maternity and Women’s Health Nursing Monilial vaginitis Abnormal vaginal discharge, Itching and burning, Pain during intercourse, irregular menstrual cycle. Pelvic inflammatory disease Multiple organisms have been found to cause PID, and most cases are associated with more than one organism. In the past, the most common causative agent was thought to be N. gonorrhoeae; however, C. trachomatis is now estimated to cause half of all cases of PID. In addition to N. gonorrhoeae and C. trachomatis, a wide variety of anaerobic and aerobic bacteria are recognized to cause PID. PID encompasses a wide variety of pathologic processes; the infection can be acute, subacute, or chronic and can have a wide range of symptoms. Microscopic examination, sample of vaginal discharge is collected and examined under a microscope for presence of yeast cells. Vaginal PH testing. Monilial Vaginitis PH is 4 – 4.5. Culture on specific type of Candida that is causing the infection to find the sensitivity to antifungal medications. PCR Testing of Candida vaginal sample. Treatment with antifungal meds clortirmazole, miconazole or fluconazole. PID is difficult to diagnose because of the accompanying wide variety of symptoms. The CDC recommends treatment for PID in all sexually active young women and others at risk for STIs if the following criteria are present and no other cause or causes of the illness are found: lower abdominal tenderness, bilateral adnexal tenderness, and cervical motion tenderness. Other criteria for diagnosing PID include an oral temperature of 38.3°C (100.9 °F) or above, abnormal cervical or vaginal discharge, elevated erythrocyte sedimentation rate, elevated Creactive protein, and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis (CDC, 2021d). Perhaps the most important nursing intervention is prevention. Primary prevention includes education about preventing the acquisition of STIs, and secondary prevention involves preventing a lower genital tract infection from ascending to the upper genital tract. Instructing women in self-protective behaviors such as practicing risk-reduction measures and using barrier methods is critical. Also important is the detection of asymptomatic gonorrheal and chlamydial infections through routine Prevention patients need to practice good hygiene, such as wearing cotton underwear, avoid douching, healthy diet, low in sugar, practice safe sex. Health education is central to effective management of PID. The nurse explains to the woman the nature of her disease and encourages her to comply with all therapy and prevention recommendati ons. The necessity of taking all medication even if symptoms disappear is emphasized. The nurse counsels the woman to refrain from sexual intercourse until her treatment is complete and provides contraceptive counseling. A NURS 3450 Maternity and Women’s Health Nursing screening of women with risky behaviors or specific risk factors such as age. All women who have been diagnosed with PID should be tested for gonorrhea, chlamydia, HIV, and syphilis (CDC, 2021). Although treatment regimens vary with the infecting organism, a broadspectrum antibiotic is generally used. Treatment for mild to moderately severe PID may be oral medication or may involve a combination of oral and parenteral agents, and such regimens can be administered in inpatient or outpatient settings (CDC, 2021). Comfort measures include analgesics for pain and all other nursing measures applicable to pain control. The woman should have as few pelvic examinations as possible during the acute phase of the disease. During the recovery phase the woman should restrict her activity and make every effort to get adequate rest and eat a nutritionally sound diet. Follow-up laboratory work after treatment should include endocervical cultures for a test of cure. woman with a history of PID can choose an IUD as her contraceptive method, and all contraceptive methods may be continued during treatment (CDC, 2021). The potential or actual loss of reproductive ability can be devastating and can adversely affect a woman’s selfconcept. The woman may need help in adjusting her self-concept to fit reality and accept alterations in a way that promotes health. Because PID is so closely tied to sexuality, body image, and selfconcept, a woman with a diagnosis of PID will need supportive care and should be encouraged to discuss her feelings. Referral to a support group or for NURS 3450 Maternity and Women’s Health Nursing counseling may be appropriate. 3. Complete the following: a. Case study: Sexually transmitted and other infections. (2023). In Sherpath for Maternal newborn (Lowdermilk version) (12th ed.). Elsevier. H.P. is a 22-year-old female who presents to the gynecologist’s office with painful urination. Subjective Data:       Last menstrual cycle: 10 days ago Pain is burning sensation Fever Performs monthly breast self-examinations Sexually active, monogamous relationship 6 months Birth control method: oral contraception Objective Data:   Multiple vesicles inner labia, ulcerations with clear discharge T=99.9 a. What other questions should the nurse ask about the painful urination? When did the painful urination begin? How long has it been occuring? How often do you urinate? Has the frequency changed recently? Are there any other symptoms, chills, or lower abdominal pain. Have you had similar symptoms before? Have you had sexual activity recently? Any new partners? What are your hygiene practices related to genital care? What is your daily fluid intake? Are you currently taking any medications, OTC or herbal? b. What are some of the causes of painful urination? Gonorrhea, Genital Herpes, Trichomoniasis, c. Develop a problems list from objective and subjective data. Risk for infection related to unprotected sexual and possible exposure to sexually transmitted infections. Acute pain caused by genital lesions and or inflammation due to infections. Knowledge deficit in safe sex practice and prevention of sexually transmitted infections. Increased anxiety due to the bad reputation of sexually transmitted infections and the long term consequences. Nonadherence with treatment and medication that lead to reoccurring infections and complications Risk of transferring infection to sexual partners due to not updating partner or practicing safe sex. NURS 3450 Maternity and Women’s Health Nursing d. Based on the readings and subjective and objective data, what is the most likely cause of painful urination for this patient? Genital Herpes Simplex Virus Objective Data: Multiple vesicles inner labia, ulcerations with clear discharge Women with primary genital herpes have many lesions that progress from macules to papules and then form vesicles, pustules, and ulcers that crust and heal without scarring (Fig. 7.3). These ulcers are extremely tender, and primary infections may be bilateral. Women can also have itching, inguinal tenderness, and lymphadenopathy. Severe vulvar edema may develop, and women may have difficulty sitting. HSV cervicitis is also common with initial HSV-2 infections. The cervix may appear normal or be friable, reddened, ulcerated, or necrotic. A heavy watery-topurulent vaginal discharge is common. Extragenital lesions may be present because of autoinoculation. Urinary retention and dysuria may occur secondary to autonomic involvement of the sacral nerve root. Recurrent lesions are unilateral, are less severe, and usually last 5 to 7 days. Lesions begin as vesicles and progress rapidly to ulcers. Few women with recurrent disease have cervicitis. e. What should be included in the plan of care? Management is directed toward specific treatment during primary and recurrent infections, prevention of recurrences, self-help measures, and psychologic support. Systemic antiviral medications partially control the symptoms and signs of HSV infections when used for primary or recurrent episodes or as daily suppressive therapy. Three antiviral medications provide clinical benefit: acyclovir, valacyclovir, and famciclovir. Cleansing lesions twice a day with saline helps prevent secondary infection. Bacterial infection must be treated with appropriate antibiotics. Measures that may increase comfort for women when lesions are active include warm sitz baths with baking soda; keeping lesions dry by blowing the area dry with a hair dryer set on cool or patting dry with a soft towel; wearing cotton underwear and loose clothing; using drying aids such as hydrogen peroxide, Burow solution or oatmeal baths; applying cool, wet black teabags to lesions; and applying compresses with an infusion of cloves or peppermint oil and clove oil to lesions Oral analgesics such as aspirin, acetaminophen, or ibuprofen may be used to relieve pain and systemic symptoms associated with initial infections. Because the mucous membranes affected by herpes are extremely sensitive, any topical agents should be used with caution. Nonantiviral ointments, especially those containing cortisone, should be avoided. A thin layer of lidocaine ointment or an antiseptic spray may be applied to decrease discomfort, especially if walking is painful. Counseling and education are critical components of the nursing care of women with herpes infections. Information regarding the etiology, signs and symptoms, transmission, and treatment should be provided. 4. TORCH Infections Summary Complete the following table to summarize the effects on mother, fetus, and newborn (for newborn look at Chapter 35, pgs. 772 – 776) Infection Toxoplasmosis Maternal effects Most infections asymptomatic Fetal effects Congenital infection is most likely to occur Newborn effects hydrocephalus, chorioretinitis, and NURS 3450 Maternity and Women’s Health Nursing Infection Maternal effects The woman is immune after first episode (except for immunocompromised clients). Fetal effects when maternal infection develops during the third trimester. The risk of fetal injury, however, is greatest when maternal infection occurs during the first trimester. May be transmitted sexually Infection occurs during birth. Approximately 10% of clients become chronic carriers. Maternal vaccination during pregnancy should present no risk for fetus; however, data are not available. Acute infection similar to mononucleosis Other infections (Hep B) Some people with chronic hepatitis B eventually develop severe chronic liver disease such as cirrhosis or hepatocellular carcinoma. Rubella Rash; fever; mild symptoms such as headache, malaise, myalgias, and arthralgias; postauricular lymph nodes may be swollen; mild conjunctivitis Approximately 50%– 80% of fetuses exposed to the virus within 12 weeks after conception will show signs of congenital infection. Very few fetuses are affected if infection occurs after 18 weeks of gestation. The most common Newborn effects cerebral calcifications. Additional signs at birth include microcephaly, seizures, hearing loss, strabismus, petechial rash, jaundice, generalized lymphadenopathy, hepatosplenomegaly, pneumonia, thrombocytopenia, and anemia. The perinatal transmission of hepatitis B virus (HBV) from an infected mother to her fetus usually occurs during the blood exposure that occurs during labor and birth. The majority of infants who become HBsAg positive are asymptomatic at birth, although some show evidence of acute viral hepatitis. There is no specific treatment for acute HBV infection. Congenital rubella syndrome includes cataracts or glaucoma, hearing loss (the most common sign), and cardiac defects (pulmonary artery stenosis, patent ductus arteriosus, or coarctation of the aorta). Multiple other abnormalities may also be present NURS 3450 Maternity and Women’s Health Nursing Infection Maternal effects Fetal effects fetal anomalies associated with congenital rubella syndrome are deafness, eye defects (e.g., cataracts or retinopathy), central nervous system defects, and cardiac defects. Cytomegalovirus Most adults are asymptomatic or have only mild flulike symptoms. The fetus can be infected transplacentally. Infection is much more likely with a primary maternal infection. Presence of CMV antibodies does not totally prevent reinfection. The most common indications of congenital infection include hepatosplenomegaly, intracranial calcifications, jaundice, growth restriction, microcephaly, chorioretinitis, hearing loss, thrombocytopenia, hyperbilirubinemia, and hepatitis. Newborn effects including low birth weight, microphthalmia, hypotonia, hepatosplenomegaly, thrombocytopenic purpura, dermatoglyphic abnormalities, bony radiolucencies, microcephaly, and brain wave abnormalities. Severe infection can result in fetal death. Communication disorders, hearing deficits, microcephaly, and cognitive or motor impairments have been reported after the newborn period (Schleiss & Marsh, 2018). Congenital infection can occur at any point during the pregnancy. Severe sequelae occur most often when the mother is infected during her first trimester of pregnancy. CMV can be transmitted during birth or through breast milk while the mother has acute CMV infection; however, in a term infant, it is unlikely to result in clinical illness. Most newborns with congenital CMV infection are asymptomatic at birth. Clinical NURS 3450 Maternity and Women’s Health Nursing Infection Maternal effects Fetal effects Newborn effects manifestations at birth can include rash, petechiae, jaundice, hepatosplenomegaly, IUGR, microcephaly, chorioretinitis, and intracerebral calcifications (Fig. 35.7). Herpes Primary infection with painful blisters, tender inguinal lymph nodes, fever, viral meningitis (rare). Transplacental infection resulting in congenital infection is rare and usually occurs with primary maternal infection. For pregnant women with a primary varicella infection, the rate of transmission to the fetus is estimated to be approximately 25% (Schleiss & Marsh, 2018). When transmission to the fetus occurs during the first or early second trimester, congenital varicella can result in fetal death, limb hypoplasia, damage to the CNS, and eye abnormalities. When maternal varicella infection occurs between 8 and 20 weeks of gestation, the congenital varicella rate is 2%. Maternal infection that occurs in the third trimester is not associated with congenital varicella infection, but it does increase the risk of the newborn having neonatal varicella (Schleiss & Marsh). Varicella infection is more serious for the Recurrent infections are much milder and shorter. The risk mainly exists with infection late in pregnancy. NURS 3450 Maternity and Women’s Health Nursing Infection Maternal effects Fetal effects Newborn effects newborn if the mother develops varicella between 5 days before and 2 days after birth because the infant’s immune system is immature and there has been insufficient time for transplacental transfer of maternal antibodies. The death rate is high among these infants. Infants born to mothers within this time frame of exposure should receive varicella zoster immune globulin as soon as possible after birth (AAP, 2021). Chapter 8 Contraception 1. What factors should be considered when helping a patient determine best method of contraception for her? In most cases, the woman herself seeks contraception through an appointment at a health care facility, although in some situations, her partner may accompany her. The assessment and evaluation involve inquiring about the partner or partners in terms of sexual practices, risk for STIs, and commitment to using contraception. Evaluation of the couple desiring contraception involves assessing the woman’s reproductive history (menstrual, obstetric, gynecologic, contraceptive), physical examination, and sometimes current laboratory tests. The nurse must determine the couple’s knowledge about reproduction, contraception, and STIs and their commitment to any particular method. Assessment of the client begins with the following appraisals:  Determining the woman’s knowledge about contraception and her sexual partner’s commitment to any particular method  Collecting data about the frequency of coitus, the number of sexual partners, the level of contraceptive involvement, and her or her partner’s objections to any methods  Assessing the woman’s level of comfort and willingness to touch her genitals and cervical mucus  Identifying any misconceptions as well as religious and cultural factors and paying close attention to the woman’s verbal and nonverbal responses to hearing about the various available methods