Week 12 Female and Male Genitalia Assessment PDF

2023-10-26 PN Health Assessment IEPN 126 Week 12: Female and Male Genitalia Assessment Anal Rectal and Prostate Assessment 1 Developmental Considerations: Older Adult ♀ Menopause...

2023-10-26 PN Health Assessment IEPN 126 Week 12: Female and Male Genitalia Assessment Anal Rectal and Prostate Assessment 1 Developmental Considerations: Older Adult ♀ Menopause – cessation of menses – usually btw 48-51 yrs → but varies 35-60 yrs – Premenopausal (1-2 yrs) → ↓ ovarian function → irregular menses, farther apart, flow lighter → ovaries stop producing progesterone & estrogen → cells in reproductive organs dependent on estrogen → ↓ estrogen levels cause physical changes in ♀ Generalized atrophy of external and internal female organs ovaries, fallopian tubes, uterus difficult to find or palpate Pubic hair decreases Dyspareunia r/t ↓ elasticity of vaginal walls ↑ in vaginal infections r/t ↑ pH ↓ natural vaginal flora ↑ incidence of uterine prolapse r/t atrophy of pelvic musculature ↑ incidence UTI’s Changes in ♀ sexual response r/t ↓ vaginal secretions/lubrication, shorter orgasm, lack of partner (older available ♀ > older available ♂) 2 1  2023-10-26 Cultural & Social Considerations Female circumcision or female genital mutilation (FGM) – Ritual removal of part or all of external female genitalia – This is illegal in Canada but still practiced in some areas of the world – Can cause both short term and long term effects on the young girls Sexually Transmitted Infection (STI) – Chlamydia most common and rates continue to increase ♀>♂ ↑ rates in Nunavut, NWT, Yukon Untreated chlamydia: PID, ectopic pregnancy, infertility – HIV and AIDS Main risk factors: heterosexual contact and injection drug use ♀ more prone to UTI – r/t short urethra – Risk factors: abnormalities of urinary tract, pregnancy, postmenopausal status, diabetes, indwelling urinary catheter 3 Common Health Issues or Concerns Pelvic pain Uterine bleeding Vaginal burning, discharge, itching Menstrual disorders Structural conditions Urinary symptoms Hemorrhoids 4 2  2023-10-26 Subjective Data ♀ Menstrual Hx – Date of last menstrual period (LMP)? Age of 1st period? How often now? How many days does it last? Usual amt flow (light, medium, heavy)? How many pads or tampons each day or hour? Clotting? Pain or cramps before or during period? How treated? Interfere with ADL? Other assoc symptoms (bloating, cramping, breast tenderness, moodiness, spotting btw periods). Obstetric Hx – Ever been pregnant? How many times? How many babies have you had? Miscarriage or abortion? For each pregnancy describe duration, complications, labour and delivery, baby’s sex, birth wt, condition. Pregnant now? Symptoms noticed. – Gravida = number of pregnancies – Para = number of births – Abortions = interrupted pregnancies including spontaneous miscarriages and elective abortions 5 Subjective Data ♀Cont’d Menopause – Have periods slowed or stopped? Associated symptoms (hot flash, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, itching)? Treatments? If hormone replacement (HRT) how much? How is it working? Side effects? How does pt feel about going thru menopause? Self-care Behaviours – How often gyne check-up? Last Pap smear? Results? – Did pt’s mother mention taking hormones while pregnant with pt (esp. DES diethylstilbestrol which causes abnormalities in ♀ offspring requiring frequent follow-up) Urinary Symptoms – Problems urinating? Frequently and small amounts? Cannot wait to urinate? – Burning or pain when urinating? Awaken during night to urinate? – Blood in urine? Urine dark, cloudy, foul-smelling? – Difficulty controlling urine or wetting self? Urinate with a sneeze, laugh, cough, bearing down? 6 3  2023-10-26 Subjective Data ♀ Cont’d Vaginal Discharge – Unusual vaginal discharge?  amt? Character or colour (white, yellow-green, grey, curdlike, foul smelling)? When did it begin? Assoc with vaginal itching, rash, pain with intercourse? Treatment? – Meds? Use vaginal douche? Use feminine hygiene spray? How often? – What part of menstrual cycle are you in now? – Wear non-ventilating underpants, pantyhose? Past Hx – Other probs in genital area? Sores or lesions now or in past? How treated? – Abdominal pain? Surgery on uterus, ovaries, vagina? Sexual Activity – “Often women have a question about their sexual relationship and how it affects their health. Do you?” – In a sexual relationship now? Satisfactory to you and your partner? Satisfied with way you & partner communicate about sex? More than one sexual partner? Sexual preference: male, female or both? 7 Subjective Data ♀ Cont’d Contraceptive Use – Currently planning a pregnancy or avoiding? Use a contraceptive? Method? Satisfactory? Questions about this or other methods? Which methods used in past? – Discussed having children with partner? Ever had problems becoming pregnant? Sexually Transmitted Infection Contact (STI) – Any sexual contact with a partner with STI (eg. gonorrhea, herpes, AIDS, chlamydial infection, venereal warts, syphilis)? When? How treated? Complications? STI risk reduction – Any precautions to  risk of STD’s? Use of condoms at each episode of sexual intercourse? 8 4  2023-10-26 Physical Assessment General approach – Ensure that client is not menstruating at time of examination for optimal specimen collection – Inform client that there should be no use of vaginal sprays, douching or intercourse 24-48 hours prior to examination for optimal specimen collection – Instruct client to void prior to examination and obtain a sample – Instruct client to disrobe from waist to ankles – Encourage expression of client concerns and allow her visualization of equipment if a first time gynecological examination (hand held mirror) – Ensure privacy – Offer the opportunity to ask questions throughout the examination – Offer tissues to remove lubricant following the examination – Discuss the possibility of discomfort during the examination, and a small amount spotting following the procedure (Pap. Smear). 9 Objective Data ♀: Inspection External Genitalia Skin color Hair distribution Labia majora Any lesions Clitoris Labia minora Urethral opening Vaginal opening (introitus) Perineum Anus 10 5  2023-10-26 Objective Data ♀:Inspection External Genitalia Normal Note skin colour, hair distribution Labia majora symmetric, plump, well formed; in nulliparous woman → midline; following vaginal delivery → gaping, slightly shrivelled No lesions present except occasional sebaceous cysts (yellowish, 1 cm nodules, firm nontender, often multiple) With gloved hand separate labia major to inspect clitoris; labia minora are dark pink, moist, usually symmetric; urethral opening stellate or slit like and is midline; vaginal opening narrow slit or larger opening; perineum smooth with well-healed episiotomy scar if vaginal births; anus coarse skin of  pigmentation 11 Normal Findings: External Genitalia Pubic hair distribution shaped like an inverted triangle No parasites present Labia majora and minora are symmetrical; skin is slightly pigmented, intact 12 6  2023-10-26 Normal Findings: External Genitalia Urethral opening is midline; free from discharge, swelling, or redness Vaginal mucosa is pink and moist Normal vaginal discharge is clear to white, free of odor Perineum is smooth, slightly darkened Anus is dark pink to brown and puckered 13 Normal Findings: Palpation Labia are soft, free from swelling, pain, induration, or purulent discharge Vaginal muscle tone is strong in nulliparous; diminished in multiparous Perineum is smooth and firm Urethral meatus is free from pain or discharge 14 7  2023-10-26 Abnormalities of GU System Abscess of Bartholin's Gland: localized pain, skin red/hot, swelling, purulent discharge; may be secondary to gonorrhea Cystocele: bladder prolapses into vagina; feel pressure in vagina; causes stress incontinence Rectocele: part of rectum covered by vaginal mucosa prolapses into vagina; feel pressure in vagina; may be constipated Uterine Prolapse: uterus prolapses through vaginal opening Inguinal Hernia: inguinal sac herniates through internal inguinal ring 15 Cervical Cancer Risk Factors Associated with bleeding between Canadian ♀ who are older, Immigrant ♀, menstrual periods; bleeding after Aboriginal ♀ → r/t lower participation rate in regular screening menopause; unusual vaginal discharge Low socioeconomic practice Early signs include chronic ulcer and Sexually active at a young age induration Multiple sexual partners or a partner with a Diagnosed with Pap smear and biopsy history of multiple sexual partners Prior or current Hx of HPV and HSV Family hx Smoker Chlamydia infection Inadequate diet Oral contraceptives Multipara Immunosuppression (eg. Taking drugs after organ transplant, AIDS) Use of DES (diethylstilbestrol) or being biological daughter of mother who took DES 16 8  2023-10-26 Promoting Health: HPV Vaccine Help prevent cervical cancer Canadian National Advisory Committee on Immunization (2007) recommends vaccine for: – Age 9–14 years females or males 2 or 3 does schedule for non-HIV infected – Injections are at least 6 mons apart Screening – Under 25 yrs women no pap test – Over 25 – 69 yrs pap every 3 yrs – After 70 yrs every 3 yrs until 3 negative results and then stop – More frequent screening may be considered for women at high risk – ♀ who have received HPV vaccine should still take part in screening programs 17 Endometrial (Uterine) Cancer Risk factors: Most common – early menarche; malignancy of – late menopause; hx reproductive system in infertility; Canada – failure to ovulate; Associated with: – tamoxifen use; – unexpected uterine – unopposed estrogen bleeding; therapy → continuous – postmenopausal stimulation of endometrium bleeding/mucosanguinous → hyperplasia; d/c; – obesity → increases – pain; endogenous estrogen – weight loss; – uterine enlargement or mass 18 9  2023-10-26 Ovarian Cancer Risk Factors Age: ♀ ages 50 - 60 years. Second most common reproductive cancer in Inherited gene mutation: Canada – small percentage genes known to Difficult to diagnose in early stages d/t increase risk of ovarian cancer are presentation with vague symptoms: increased called breast cancer gene 1 waist size, pelvic pressure, back or abd pain, (BRCA1) and breast cancer gene 2 bloating, constipation, flatulence (BRCA2). At diagnosis 75% have already metastasized – gene mutations that cause Lynch Pap smear does not detect ovarian cancer → syndrome, which is associated with ♀ >40 yrs annual pelvic exam colon cancer, also increase a woman's risk of ovarian cancer. Estrogen hormone replacement therapy – especially with long-term use and in large doses. Early menarche Late menopause Never being pregnant (nulliparity) Fertility treatment. Smoking. Use of an intrauterine device. Polycystic ovary syndrome. 19 Other Types of Cancer Cancer of the Vulva – Usually asymptomatic until lesion becomes large – Itching, burning, pain – Bleeding or watery discharge from lesion 20 10  2023-10-26 Risk Factors: Vaginal Infections Increasing age Antibiotic use Immunodeficiency Oral contraceptive use Estrogen deficiency Diabetes mellitus Steroid use Menses Douches Alkalinization from sperm Pregnancy ↑ # of sexual partners Hygiene 21 Maintaining Gynecological Health Avoid douches, feminine hygiene sprays or use sparingly d/t disruption of natural vaginal flora and ↑ vaginal pH Do not leave tampons in vagina > 8 hrs d/t ↑ risk toxic shock syndrome Wash/wipe vaginal area from front to back to prevent contamination of vagina & urethra with fecal material Thoroughly wash diaphragms, sexual aids, etc after use Void immediately after coitus 22 11  2023-10-26 Objective Data ♀: Palpation Advanced Practice – not typically performed by RPN but knowledge of skill is testable- review textbook readings External genitalia Urethra and Skene’s glands Bartholin’s glands Support of pelvic musculature Internal genitalia - Speculum Exam 23 Speculum Exam – Advanced Practice Make note of the equipment used for a gynecological exam. **It is not within the scope of a basic nursing preparation to perform the speculum examination of the internal genitalia. Practice is more focused on patient teaching, preparing the patient for and assisting the examiner with the internal genitalia examination. **It is an expectation that the nurse performs an examination of the external genitalia. 24 12  2023-10-26 Normal Findings: Internal Genitalia Cervix is pink, pale (menopause), or blue (pregnancy) Cervix is midline Glistening pink cervical epithelium Cervical os is round in nulliparous; a horizontal slit in multiparous 25 Male Genitalia Assessment 26 13  2023-10-26 Developmental Considerations: Older Adult No definite end to fertility Sperm production begins to decrease at 40 years → but continues into 80’s and 90’s Testosterone declines gradually after age 55 years → so gradual physical changes not evident until later → other changes r/t ↓ muscle tone, ↓ subcutaneous fat, ↓ cell metabolism Pubic hair ↓ and may turn grey Penile and testicular atrophy Slower and less intense sexual response r/t ↓ testosterone Sexual expression in later life – Physical changes do not interfere with libido 27 Cultural and Social Considerations Circumcision of male infants – Common reasons include: hygiene, avoidance of a later need, father’s circumcision status, religious and cultural values No medical indication for male neonatal circumcision (Canadian Paediatric Society, 2002) – Not covered by provincial health insurance – However, research indicates reduces acquisition of HIV, herpes simplex virus type 2, prevalence of HPV; decreases risk for STIs Parental knowledge of care of uncircumcised penis – By age 3-4 yrs can be taught to clean under foreskin – When reaches puberty, need to clean under foreskin daily HPV vaccine approved for boys and men (Public Health Agency of Canada, 2011) – HPV cause genital warts – Associated with cancers of penis, anus and head and neck 28 14  2023-10-26 Focused Health History Related to Common Symptoms Pain Problems with urination Male sexual dysfunction Penile lesions, discharge, or rash Scrotal enlargement Hernias Dribbling (urinary) 29 Subjective Data ♂ Urinary S&S – Frequency, urgency, nocturia: urinating more than usual? Feels like cannot wait? Awaken during night to urinate? How often? When did this start? – Dysuria: pain or burning when urinating? – Hesitancy and Straining: trouble starting urine stream? Need to strain to start or maintain stream?  in force of stream (narrowing or becoming weaker)? Dribbling (need to stand closer to toilet)? When finished, still feel need to urinate? UTI’s? – Urine Colour: clear or discoloured? Cloudy? Foul- smelling? Bloody? 30 15  2023-10-26 Subjective Data ♂ Past Genitourinary Hx – Difficulty controlling urine? Accidentally urinate when sneeze, laugh, cough, bear down? Hx kidney disease, kidney stones, flank pain, UTI’s, prostate trouble? Penis – Pain? Lesions? – Discharge? If so, how much?  or  since discharge started? Colour? Odour? Associated with pain or urination Scrotum – Perform testicular self-examination? Any lump or swelling on testes? – Any change in size of scrotum? Any bulge or swelling in scrotum? How long? Ever been told you have a hernia? Any dragging, heavy feeling in scrotum 31 Subjective Data ♂ Sexual Activity and Contraceptive Use – In a relationship involving sexual intercourse now? Satisfactory to you and partner? Satisfied about how communicate with your partner about sex? – “Occasionally a man notices a change in his ability to have an erection when aroused. Have you noticed any changes?” – Use contraceptive? Which method? Satisfactory? Any questions about this or other methods? – Number of sexual partners in past 6 months? – Sexual preference: female, male or both? STD Contact – Any sexual contact with partner having STD (eg. gonorrhea, herpes, AIDS, chlamydia, venereal warts, syphilis)? When? Did you get the disease? How treated? Complications? – Use condoms to help prevent STD’s – Any question or concerns about any of these diseases? 32 16  2023-10-26 Testicular Cancer Risks Age 15 – 49 years Higher incidence in males 15-29 yrs Genetic background – highest in Caucasian men Cryptorchidism (undescended testicle at birth) Hx of testicular cancer in other testicle Family hx – Increased risk if brother or father has had testicular cancer 33 Prostate Cancer Risks Third leading cause of cancer death in men Family hx of prostate cancer Age – Highest incidence in older men – 75% new cases occur in men older than 65 years Heritage – Men of African genetic background have highest incidence of prostate cancer (two time higher than white men) – Worldwide: highest prevalence is in North America and Northwestern Europe 34 17  2023-10-26 Penile Cancer Risks Phimosis (the foreskin of penis cannot be pulled back over the glans) – this is a modifiable risk factor Age ≥ 60 years Compromised personal hygiene Sexual promiscuity Use of tobacco products Possible link with human papillomavirus (HPV) 35 Objective Data: Inspection and Palpation♂ Penis – Check for lesions, warts, swelling – Slide foreskin back to assess for easy return – Assess urethral meatus; should be  central; no stricture should be noted; should be pink, smooth and w/o discharge (if d/c noted, obtain swab for culture) – Shaft should be smooth, semi-firm, non-tender Priapism – prolonged painful erection of the penis without sexual stimulation and not relieved by intercourse or masturbation Scrotum – Check for symmetry, swelling, lesions – Palpate testes; should by oval, firm, rubbery, smooth, equal bilaterally, freely movable, slightly tender to moderate pressure – Each epididymis feels discrete, softer than testis, smooth and nontender – Spermatic cord from epididymis to inguinal ring should be smooth and nontender – Transillumination: if swelling or mass, darken room → place flashlight behind scrotal contents → normally does not transilluminate 36 18  2023-10-26 Objective Data – Hernia & Lymph Nodes Be aware of your scope of practice within your facility for this skill: Check for hernia—Inspect and palpate – Patient standing and straining down(bearing down) – Palpation technique - Palpate inguinal and femoral areas: don gloves → ask pt to shift wt to Lt leg while you examine Rt side → repeat on other side Inguinal lymph nodes— Palpate – Horizontal chain along groin and vertical chain along upper inner thigh Copyright © 2019 Elsevier, Inc. 37 Inspection:Normal Findings Triangle-shaped distribution of pubic hair Penile skin is free of lesions and inflammation Penile shaft skin is loose and wrinkled Foreskin retracts easily – Paraphimosis Condition in which the retracted foreskin develops a fixed constriction proximal to the glans penis. – Phimosis = Constriction of the distal penile foreskin that prevents normal retraction over the glans. 38 19  2023-10-26 Inspection: Normal Findings No discharge from foreskin Scrotal skin is rugated, thin, and pigmented No lesions, nodules, swelling, or inflammation are present in the scrotal area Left scrotal sac may be lower than right Testes and epididymites do not transilluminate Urethral meatus is centrally located, pink, and without discharge No bulges or swelling are present in the inguinal area 39 Palpation: Normal Findings Penis is nontender Pulsations are present on dorsal side of the penis Urethral meatus is free of discharge Testicles are firm, ovoid, smooth, and equal in size Spermatic cord is smooth and round Small, freely mobile lymph nodes are present in the inguinal area The inguinal and femoral areas free of bulges or palpable masses No bowel sounds are present in the scrotum 40 20  2023-10-26 Testicular Self-Examination (TSE) Teach testicular self-examination for testicular cancer; early detection results in cure rate of almost 100% Signs: lump, pain, heaviness, or dull ache Risk factors: Age 15 to 49 years Delayed descent of testicles Family history Abnormal development of testicle T = Timing (once a month); S = Shower(better relaxation of scrotal sac); E = Examination(check for changes) Copyright © 2019 Elsevier, Inc. 41 Anal, Rectum and Prostate Assessment 42 21  2023-10-26 Developmental Considerations Newborn=first stool-meconium=patency of rectum Puberty=prostate doubles to reach adult size Benign prostatic hypertrophy evident males at age 40 and increases with age Risk of developing prostate cancer increases with age 43 Common Health Issues or Concerns Rectal bleeding Rectal pain Anal incontinence Constipation Diarrhea Pruritus Palpable mass 44 22  2023-10-26 Subjective Data Usual Bowel Routine – Regular? How often? Usual colour? Hard or soft? Pain while passing BM? Change in bowel habits – Loose stools or diarrhea? Started when? Associated with N&V, abd pain, food ingested? – Eaten at a restaurant recently? Anyone else in group affected the same way? – Travelled to foreign country during last 6 months? – Stools hard? Started when? Rectal bleeding, blood in stool – Black or bloody stools? When did first notice? Colour (bright red, dark red- black)? How much blood: spotting on toilet paper or outright bleeding with stool? – Clay-coloured stools? – Mucus or pus in stool? – Need to pass gas frequently? 45 Subjective Data Cont’d Medications – Prescription and OTC? Laxatives or stool softeners? How often? Iron pills? Use enemas to move bowels? How often? Rectal conditions – Probs in rectal area (itching, pain, burning, hemorrhoids)? How treated? Hemorrhoid preparations? Ever had a fissure or fistula? How treated – Ever had prob controlling bowels? Family history – Polyps, cancer in colon or rectum, inflammatory bowel disease, prostate cancer? Self-care behaviours – Usual amt high-fibre foods in daily diet (cereals, apples or other fruits, vegetables, whole grain breads)? Glasses of water/day? – Date of last digital rectal exam, stool blood test, colonoscopy, prostate-specific antigen blood test? 46 23  2023-10-26 Colorectal Cancer Third most common cancer in Decrease risk by: Canadian men and women – Diet high in veggies and fruit Risk factors – Diet high in fibre – Age >50 years – Diet low in animal fats – History of polyps S & S: – Family history of colorectal – None in early stages cancer – When tumour causes bleeding or blocks – Familial adenomatous bowel polyposis or hereditary Change in bowel habits (diarrhea or nonpolyposis colon cancer constipation); abd discomfort (bloating, sensation of – Inflammatory bowel disease fullness, cramps) – Diet high in red and processed Blood in stool (bright red or very dark meats red) – Alcohol consumption Stools narrower than usual – Smoking Strong urge to defecate – Physical inactivity Feeling that bowel not completely emptied – Obesity N&V – Ashkenazi (Eastern European Fatigue Jewish) ancestry Weight loss 47 Promoting Health: Screening for Colorectal Cancer Recommendations for screening – Canadian Cancer Society (2016) recommends screening for men and women aged 50+ years every 2 years – People at high risk can be screened at an earlier age – Fecal occult blood test (gFOBT, iFOBT, or FIT) – Positive FOBT may be followed up with colonoscopy, sigmoidoscopy, double-contrast barium enema Copyright © 2019 Elsevier, Inc. 48 24  2023-10-26 Promoting Health: Screening for Prostate Cancer Most common cancer in Canadian men Risk factors – Age >65 years – Family history – Diet high in fat – African ancestry Screening – Discuss risks and benefits of testing with men age 50 years and older – DRE (digital rectal examination) – PSA (prostate-specific antigen) Canadian Cancer Society, 2010 Copyright © 2019 Elsevier, Inc. 49 Objective Data Collection General Approach Encourage client to void prior to the examination and obtain sample. Position client in L lateral position for inspection, for palpation have client stand and bend over examination table or assume knee-chest position. Ensure privacy Explain each step in the examination BEFORE you perform it Use a gentle, firm touch and gradual movements Communicate throughout the examination. Maintain dialogue to share information. Review content page 612 picture 23.3 50 25  2023-10-26 Objective Data: Equipment Preparation – Position Equipment needed – Penlight – Lubricating jelly – Glove Guaiac test container (for gFOBT) - guaiac-based fecal occult blood test chemical reaction on a paper card to find traces of blood in stool from adenomatous polyps or tumors 51 Inspection and Palpation Inspect Perianal Area – Spread buttocks wide apart and inspect perianal area – Anus normally looks moist and hairless with coarse folded skin that is more pigmented than perianal skin; anal opening tightly closed; no lesions – Ask pt to hold breath and bear down; no break in skin integrity or protrusion should be present 52 26  2023-10-26 Inspection: Normal Findings Perineum and sacrococcygeal areas – Tissue is smooth, intact, free of tenderness Anal mucosa – Tissue is pigmented, coarse, moist, and hairless 53 Inspection: Abnormal Findings Hemorrhoids = Dilation of hemorrhoidal veins in the anorectum. Rectal prolapse = Protrusion of the rectal mucosa through the anal orifice. Anal fissures = Linear tear in the epidermis of the anal canal Anorectal abscess = Undrained collection of perianal pus of the tissue spaces in and adjacent to the anorectum. 54 27  2023-10-26 Inspection: Common Abnormal Findings Anorectal fistula = Hollow, fibrous tract lined by granulation tissue and filled with purulent or serosanguinous discharge; has an opening inside the anal canal or rectum, and one or more orifices in the perianal skin. Anal warts Anal incontinence Infestations: pinworms or fungal infections make perineal area appear irritated and eurythmic 55 Abnormal Findings Anal Region Rectum and Prostate Gland Pilonidal cyst or sinus Rectum Anorectal fistula – Abscess – Rectal polyp Fissure – Fecal impaction Hemorrhoids – Carcinoma Rectal prolapse Prostate gland Pruritus ani – Benign prostatic hypertrophy (BPH) – Prostatitis – Carcinoma Copyright © 2019 Elsevier, Inc. 56 28  2023-10-26 Week 13 – IEPN 126 Final Exam- online – To cover all material from week 1 to week 12 discussed in lecture, in textbook, that you were directed to read and lab – All multiple choice questions Good Luck!! 57 29