Medical-Surgical Nursing 13th Edition

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Assessment & Mgmnt. of Female Physiologic Processes
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The vagina is protected by its normally low pH of?
And is maintained in part by the actions of?

pH (3.5 to 4.5), Lactobacillus acidophilus, the dominant bacteria in a healthy vaginal ecosystem.


The epithelium of the vagina is highly responsive to estrogen which induces?

Glycogen formation:
Glycogen is a multibranched polysaccharide of glucose that serves as a form of energy storage.


When estrogen decreases during lactation & menopause, glycogen also decreases and may lead to?



As estrogen production ceased during peri- and postmenopausal periods, the vagina & labia may?

Atrophy (thin), making the vaginal area more susceptible to infection.


Vaginitis is a group of conditions that cause vulvovaginal systems such as?

Itching, irritation, burning, and abnormal discharge.


Assessment: Factors that may initiate or predispose the vagina to Vulvovaginal infection include?

A decrease in flora due to antibiotic use, pregnancy, tight, nonabsorbent, heat and moisture-retaining clothing, Diabetes, corticosteroid or oral contraceptive use, perfumes, soaps, Psychogenic factors such as stress or abuse, sex.


Most common cause of Vaginitis?

Bacterial vaginitis (pH >4.7), followed by vulvovaginal candidiasis (fungal/yeast) and trichomoniasis.


What is Candidiasis or Vulvovaginal Candidiasis?

Fungal or yeast infect. caused by strains of Candida. Candida albicans accounts for MOST cases. Many woman w/ healthy ecosystem harbor Candida but are asymptomatic.


When do Candidiasis(yeast infect) Occur?

-More common in Preg.
-w/ systemic condition, Diabetes or HIV
-Medications Corticosteroid, oral contraceptive, Antibiotics(decrease bacteria, good flora)


Clinical manifestations of Trichomonas vaginalis (flagellated protozoan) that may increase risk of contracting HIV, play a role in development of cervical neoplasia, PID, and infertility are?

Inflammation of the vaginal epithelium, producing burning, itching, & Frothy yellow-white or yellow-green vaginal discharge.


Treatment for Trichomonas vaginalis (flagellated protozoan)?

TX: 1x loading dose or smaller dose 3x a day for 1wk, PO Metronidazole (metallic taste, n/v) or tinidazole (Tindamax)- AVOID Alcohol.


What are the Clinical manifestations of Bartholinitis (infection of the greater vestibular gland that produces lubrication for intercourse)?Causes are Escherichia coli, T. vaginalis, Staphylococcus, Streptococcus, Gonococcus.

Erythema around vestibular gland, Swelling & edema, Abscessed vestibular gland.

TX: Drain abscess; provide antibiotic therapy.


What is the test and procedure for diagnosing Bacterial Vaginosis?

Whiff test; by adding a drop of potassium hydroxide to a glass slide with a sample of vaginal discharge, which releases amines.


Nursing Diagnosis for Vulvovaginal infections include?

-Impaired comfort related to burning, order, or itching from the infectious process.
-Anxiety related to stressful systems.
-Risk for infection or spread of infection.
-Deficient knowledge about proper hygiene and preventative measures.


Nursing Interventions for Vulvovaginal infections include?

-Relieving impaired comfort with meds, sitz bath.

-Reducing anxiety by explaining the cause & S/S, ways to prevent infections.

-Preventing reinfection/Spreading by explaining that candidiasis is not an STI, ways to prevent such as rest, decrease stress, healthy diet low in refined sugars. Advise pt some antibiotics cause yeast infections it is not an allergic reaction. For suppository & applicator use for creams the nurse may demonstrate procedure on plastic model of pelvis/vagina & instruct pt to recline for 30min after inserted.

-Promoting HM & Community-Based Care, teach pt douching & feminine sprays are unnecessary daily baths/showers, proper hygiene keep the perineal area clean. Douching eliminates normal flora.


Diagnostic Examinations and Tests?

-Pelvic exam
-Pap smear
-Colposcopy an cervical biopsy
-Cryotherapy and laser therapy
-Cone biopsy & loop electrosurgical excision(LEEP)-removal of abdominal tissue.
-Endometrial biopsy
-Dilation & Curettage
-Laparoscopy(pelvic peritoneoscopy) and hysteroscopy.


Menstrual Disorders?

-Premenstrual Syndrome
-Dysmenorrhea(painful menses)
-Amenorrhea(No menses) normally start 12yr, 13 if athletic

-Abnormal uterine bleeding
*Menorrhagia(heavy bleeding >2 full pads daily)
*Metrorrhagia(irregular bleeding)
*Postmenopausal bleeding (could be cancer)


HPV Pathophysiology?

-More than 100 types exist. Most common strains of HPV 6, 11, usually cause condylomata(warty growths) on vulva, rarely premalignant, low risk for cervical cancer.

-Incidence high for HPV in young sexually active woman, usually disappears as result of effective immune system response.

-Also found in young girls non-sexually active(perinatal transmission-being researched, as is autoinoculation(self spreading herpes to other parts of your own body.


High risk Oncogenic types of HPV cause almost all cases of Cervical Cancers and include strains?

-16, 18, 31, 45 and affect the cervix, causing cell changes or dysplasia(found on a Papanicolaou{Pap} smear.
-Effects of these strains are usually invisible on exam but may be see on Colposcopy(special magify device, if abnormal a biopsy tissue sample may be taken).


Medical Management of HPV includes?

-Tx of external warts by Dr. are trichloroacetic acid, podophyllin (Podofin, Podocon), cryotherapy (freeze), surgical removal.

-Topical agents applied by pt to external lesions are podofilox (Condylox),and imiquimod (Aldara)do not use agents during preg. Mild pain or local irritation w/ use of med.

-Woman w/ HPV need annual PAP Smears due to the potential of HPV to cause dysplasia(abnorm changes in cells). Transmission can occur during skin-to-skin in areas not covered by condoms.


Prevention of HPV includes?

-CDC recommends routine vaccin. of boys/girls 11-12yrs before sexually active.

-Admin in 3 IM doses w/ initial dose followed by 2nd in 2 mo. then 3rd dose in 6 mo. after the 1st. Completion of all 3 doses is important for immunity to develop. Woman still need cervical screenings as recommended.


Herpes Pathophysiology and different types?

There are 9 types of herpes viruses belonging to 3 dif. groups that cause infections in humans.

-Herpes simplex Type 1(HSV-1)cold sores.

-Herpes simplex type 2(HSV-2)genital herpes, varicella zoster or shingles; Epstein-Barr virus; cytomegalovirus; human B-lymphotrophic virus; and others. STI, but can be transmitted asexually from wet surfaces, self-transmission(touching cold sore then genitalia), initial infec. very painful.

-Close human contact by mouth, oropharynx, mucosal surface, vagina, or cervix appears necessary to acquire infection. Other susceptible sites are skin lacerations, conjunctivae(eye).


Clinical Manifestations of Herpes are?

-Itching, pain as infected area becomes red & edematous. May begin w/ macules, papules & progress to vesicles & ulcers.

-Primary site in woman is labia, for men the glans penis, foreskin, or penile shaft.

-Flu like s/s may occur 3-4 days after lesions appear. Inguinal lymphadenopathy(enlarged lymph nodes in groin), H/A, myalgia(aching muscles), dysuria.

-Lesions last 4-15 days before crusting over. Other potential problems are aseptic meningitis, neonatal transmission, & severe emotional stress related to diag.


Medical Mgmt of Herpes?

-No Cure for HSV-2 tx aimed at relieving symptoms, prevent spread, initiating counseling.

-Med. 3 oral antiviral agents. acyclovir (Zovirax), valacyclovir (Valtrex), famciclovir (Famvir)can suppress systems & shorten course of infection.


Nursing Diagnosis for Herpes?

-Acute pain related to the genital lesions.
-Risk for infection or spread of infection.
-Anxiety related to the diagnosis.
-Deficient knowledge about the disease and its management.


Nursing Interventions for Herpes?

-Relieving Pain, keep lesions clean, sitz baths, lose soft clothing, aspirin & other analgesic agents for pain.

-Preventing Infection/Spread proper hand hygiene, use barrier methods w/ sex, can spread when no lesions are present.

-Relieving Anxiety: Nurse serves as important source of support by listening to pts concerns, providing info & instruction. Pt may be upset w/ partner for infection or need assistance discussing the infect w/ partner.

-Increasing Knowledge about the disease and its Tx:
because of the increased risk of HIV/other STIs in the presence of skin lesions, an important part of pt education involves instruct pt to protect herself from exposure to HIV & other STIs.


Upon completion of hm care education pt/caregiver will be able to?
p1654, 57-2

-State herpes transmitted mainly by direct contact.
-State abstinence frm sex req. during tx.
-State sex during outbreak increases risk for transmission & increases chance of contracting HIV.
-State transmission is poss in absence of lesions.
-State condoms may provide some protection against viral transmission.
-Explain OB should be informed hx of herpes. In cases of recurrence at birth c-section may be req.
-Describe approp. hygiene practices(hand, perineal, gentle washing of lesions w/ mild soap, running water & lightly drying lesions), avoiding occlusive(air tight)ointments, strong perfumed soaps/bubble bath.
-State control of condition may req. changes in sexual behavior and/or use of meds.
-Describe strategies to avoid self-infect(avoid touching lesions during outbreak).
-Explain rational for avoiding self-infect(lesions can become infected frm germs on hand, & the virus frm the lesion can be transmitted frm hand to another area of body/another person).
-Describe health promotion strategies: wear loose, comfortable clothing; eat a balanced diet; get adequate rest/relaxation.
-state rational for avoiding exposure to sun(can cause recurrences/skin cancer.
-Identify importance of taking meds, keeping follow up apts & reporting repeated recurrences.
-Describe poss benefits of joining groups to share solutions & experiences & hear about newer tx.


What is Endocervicitis & Cervicitis?

-Inflammation of the mucosa & glands of the cervix that may occur when organisms gain access to the cervical glands after intercourse/abortion/vag delivery.
-Inflammation can irritate the cervical tissue resulting in spotting/bleeding & mucopurulent cervicitis (inflam. of cervix with exudate)


Most common causes of Endocervicitis

-Chlamydia & Gonorrhea(often coexist), sometimes Mycoplasma (bacterial w/out cell wall, resistant to antibiotics.
-Serious complications include:pelvic infect., risk of ectopic preg., Infertility.


S/S of Chlamydial & Gonorrhea infections?
Diagnosed by?

-Often no symptoms, but cervical discharge, dyspareunia (painful sex), dysuria, bleeding. If preg. still birth, neonatal death, and premature labor may occur.
-Diag confirmed by urine culture or sample of cervical or penile discharge.


Medical Mgmt of Chlamydia & Gonorrhea includes?

-Doxycycline(Vibramycin) 1wk or single dose of azithromycin(Zithromax). Due to high incidence of coinfection w/ Chlamydia/Gonorrhe tx for both should be included.

-Preg. woman cautioned not to take tetracycline instead take Erythromycin.

-Cultures for chlamydia & other STIs obtained after sexual assault, tx prophylactically.

-Annual screenings for ALL sexually active woman 25 and younger, >25 screened if risk factors present


Nursing Mgmt for Chlamydia & Gonorrhea includes?

-Assist pt. in assessing their own risk. Recognition of risk is FIRST step BEFORE changes in behavior occur.
-Reinforce need for annual screening. Because STIs may have a serious effect on future health/fertility many can be avoided by use of condoms/spermicides, choice of partners.
-Nurses can play a major role in counseling pts addressing knowledge deficits & correcting misinformation reducing morbidity & mortality.


With Pelvic Inflammatory disease PID all pt are prone to complications of Ectopic pregnancy due to fallopian tube obstruction and need to be informed of the S/S which are?

Pain, abnormal bleeding, delayed menses, faintness, dizziness, and SHOULDER PAIN.


Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome is usually fist detected and treated by?

-Nurses/other woman's health care clinicians because HIV may be detected during prenatal testing?screenings for STIs.

-Thus clinicians need to be knowledgeable about this disorder and sensitive to women's issues/concerns.

-Use of antiretrovial agents for preg woman w/ HIV is critical because they significantly decrease perinatal transmission of the infection to the fetus.


When are woman who are at risk for HIV offered testing by a nurse or counselor?

-After informed consent is obtained. Early detection permits early tx to delay progression of the disease.
-Nurse must remember, most women Do Not see themselves as being at risk for HIV.


What is Pelvic Inflammatory Disease PID?

-Inflam. of the pelvic cavity that may begin w/ cervicitis & involve the uterus(endometritis), fallopian tubes(salpingitis), ovaries(oophoritis), pelvic peritoneum, or pelvic vascular system.

-May be acute, subacute, recurrent, or chronic & localized or widespread.


PID is caused by?

-Bacteria but may be attributed to a virus, fungus, or parasite.

-Gonorrheal & Chlamydial organisms are common causes.

-Most cases are associated w/ more than 1 organism.


PID Complications have Short & long-term consequences such as?

-Pelvic or generalized peritonitis, abscesses, strictures, Fallopian tubes becoming narrow & scarred.

-Increasing risk of ectopic pregnancy(fertilized eggs trapped in the tube), infertility, recurrent pelvic pain, tubo-ovarian abscess(a collections of purulent material), recurrent disease.

-Adhesions are common, often resulting in chronic pelvic pain; eventually may require removal of uterus, fallopian tubes, and ovaries.

-Bacteremia(bacteria in blood), septic shock(infect. leads to life threatening Low BP)

-The true incidence of PID is unknown because some cases are asymptomatic & others present atypically.


Pathophysiology of PID?

-The exact pathogenesis of PID has not been determined but presumed organisms enter through the vagina, pass through the cervical canal, colonize the endocervix, then move upward into the uterus. Under various conditions, the organism may proceed to 1/both fallopian tubes, ovaries then in the pelvis.

-In bacterial infections that occur after childbirth or abortion, pathogens are disseminated(spread) directly through the tissues that support the uterus by way of the lymphatics/blood vessels. In preg the increased blood supple required by the placenta provides a wider pathway for infection.

-These infections can cause perihepatic inflammation when the organism invades the peritoneum(thin membrane lining the abdominal wall/covering abdom. organs).

-In rare instances, organisms(tuberculosis) gain access to the reproductive organs through the bloodstream from the lungs.


One of the most common causes of Salpingitis(inflam fallopian tubes) is?

Chlamydia, possibly accompanied by gonorrhea.


Pelvic infection is most often sexually transmitted but can also occur with invasive procedures such as?

-Endometrial biopsy, abortion, hysteroscopy(view uterus), or insertion of an intrauterine device.

-Bacterial vaginosis may predispose women to pelvic infection.


Risk factors for PID include?

-Early age first time of sex
-Multiply partners
-Freq. douching
-Substance abuse
-Hx of STIs/pelvic infections
-No protection


PID includes?

-Endometritis(lining of uterus)
-Pelvic Cavity Infection.


What are the clinical manifestations of PID?

-Begin with purulent discharge, dyspareunia(pain w/ sex), lower abdom. pelvic pain/tenderness after menses. Pain may increase after voiding or defecation. Fever, N/V, H/A, anorexia.

-During pelvic exam, intense tenderness may be noted on palpation of uterus or movement of cervix. Symptoms may be acute/severe or low grade/subtle.


Medical Mgmt. of PID

Broad spectrum antibiotic therapy Usually combo of:


Indications for hospitalization from PID include?

Surgical emergencies, pregnancy, no clinical response to oral antimicrobial therapy, inability to follow or tolerate outpatient oral regimen, severe illness(N/V, High fever), tubo-ovarian abscess(pocket of pus formed during infect).


Interventions for PID

-Laparoscopic(sm incision surgery for Adhesions)
-STD testing


Nursing Mgmt. for PID includes?

-Assess physical/emotional effects. Pt may feel well 1 day then discomfort the next.

-May suffer constipation/menstrual difficulties.

-Recording Vitals, I/O, Vaginal discharge(amount, color, odor, consistency) necessary as a guide for therapy.

-Nurse administers analgesics for pain. Adequate rest/healthy diet are encouraged.

-Nurse minimizes transmission of infect by adhering to appropriate infect control practices & performing meticulous hand hygiene.


Promoting Home/Community-Bases Care (Pt teaching) for PID?

-Inform pt how pelvic infections occur, how to control/avoid & S/S.

-Inform ALL pt w/ PID of S/S of ectopic preg.

-If reinfection occurs/spreads S/S may include: abdominal pain, n/v, malaise, malodorous(smelly) purulent vag. discharge, leukocytosis(increased WBC).


Upon completion of hm care education with PID pt/caregiver will be able to?
pg1657, 57-3

-State any pelvic pain/abdom discharge after: sex, birth, pelvic surgery, needs evaluated ASAP.

-State abx(antibiotics)may be Rx after insertion of intrauterine devices.

-Describe proper perineal care/wiping front-back.

-State douching reduces natural flora, may introduce bacteria upward.

-Identify importance of consulting HCP of unusual vaginal discharge/odor.

-Discuss importance of proper: nutrition, exercise, wt. control. Safe sex practices: condom, 1 partner.

-Explain importance of consistent use of condoms before sex or any penile-vaginal contact if there is any chance of transmitting infect.



Structural Disorders - Fistulas of the Vagina are?

-Abnormal opening between 2 internal hollow organs or between an internal hollow organ & the exterior of the body.

-The name of the fistula indicates the 2 areas that are connected abnormally-ex. a vesicovaginal fistula is an opening between the bladder & vagina, & a rectovaginal fistula is an opening between the rectum & vagina.

-Fistulas may be congenital in origin but are most common in developing countries due to labor complications.

-In US they occur most often due to injury during surgery, vaginal delivery, IBS, radiation therapy, or disease process such as carcinoma.


Clinical Manifestations of Fistulas of the Vaginal are?

-Vesicovaginal fistula, urine escapes continuously into the vagina.

-Rectovaginal fistula, there is fecal incontinence, and flatus is discharged through the vagina. The combination of fecal discharge w/ leukorrhea(thick whit/yellow/greenish discharge)resulting in malodor(smelly odor) that is difficult to control.


Assessment and Diagnostic Findings of Fistulas?

-Hx of symptoms.

-Diag: Methylene blue dye is commonly used to help delineate the course of the fistula.

-Vesicovaginal= Dye is instilled in the bladder and appears in the vagina.

-After a neg methylene blue test result, indigo carmine is injected intravenously; the appearance of the dye in the vagina indicates ureterovaginal fistula.

-Cystoscopy or IV pyelongraphy may then be used to determine the exact location.


Medical Mgmt of Fistulas?

Goal is to eliminate the fistula & tx infection & excoriation. May heal on own but often require surgery.

-To promote healing: proper nutrition, cleansing douches & enemas, rest, admin of intestinal antibiotics.

-Rectovaginal fistula heals faster when pt eats a low-residue diet & when affected tissues drains properly. Warm irrigations promote healing.

-Sometimes fistulas dnt heal & can't be surgically repaired. So care must be planned & implemented on an individual basis.

-Cleanliness, freq sitz baths, and deodorizing douches are req as are perineal pads & protective undergarments.

-Meticulous skin care is nec. to prevent excoriation.

-Applying bland creams or lightly dusting w/ cornstarch may be soothing.

-Attending to the pts social & psychological needs is essential aspect of care.

-If pt is to have fistula repaired surgically, preoperative tx of any existing vaginitis is important to ensure success.


Fistulas are usually related to obstetric, surgical, or radiation trauma. What are other poss causes of Fistulas?

-Crohn's disease or lymphogranuloma venereum(sexually transmitted bacterial disease)

-Despite the best surgical intervention, fistulas may reoccur after surgery.

-Medical follow up continues for 2yrs to monitor poss recurrence.


What are the different types of Pelvic Organ Prolapse:

-Cystocele, Rectocele, Enterocele.


What is Cystocele? S/S?

-BLADDER sags into the vaginal space due to lack of structural support(result of child birth or hysterectomy).

-Usually appears yrs later when genital atrophy(wasting away)associated w/ aging occurs, but younger, multiparous, premenopausal woman may also be affected.
-S/S Pelvic Pressure, stress incontinence.


What is Rectocele? S/S?

-Portion of the RECTUM sags into the vagina as a result of weakening of the posterior vaginal wall.

-S/S Pelvic pressure, backache, constipation (pt may actually have to insert fingers into the vagina to push feces up to defecate.


What is Enterocele?

-Protrusion of the INTESTINAL Wall into the vagina. Prolaps results from a weakening of the support structures of the uterus itself; the cervix drops and may protrude from the vagina.

-If complete prolapse occurs, it may also be referred to as Procidentia(falling down of an organ from original position)


Causes of Pelvic Organ Prolapse?

-Age & parity(# of full term births)can put a strain on the ligaments & structures that make up the female pelvis/pelvic floor.

-Childbirth can result in tears of the levator sling musculature, resulting in structural weakness.
-Hormone deficiency also may play a role.


Clinical Manifestations of Pelvic Organ Prolapse?

-Because the Cystocele causes the anterior vag wall to bulge downward, the pt may report pelvic pressure & urinary incontinence, freq, & urgency. Back/pelvic pain as well.

-Symptoms of rectocele resemble cystocele w/ 1 exception: Instead of urinary symptoms, pts may experience rectal pressure. Constipation, uncontrollable gas, & fecal incontinence may occur in pts w/ complete tears. Dyspareunia(painful sex)may occur w/ these disorders.


Medical Mgmt of Pelvic Organ Prolaps?

-Kegel exercises, which are more effective in the early stages of a cystocele. Squeeze Pubococcygeal Muscle-hold 10 secs. relax 10 secs., repeat 15x daily (Book states 30-80x daily).

-Pessary ring-doughnut shaped, made w/ various materials, such as rubber or plastic.


-Pt should have pessary removed, examined/cleaned by health care provider at prescribed intervals. At these checkup vag. walls should be examined for pressure points or signs of irritation. There should be no pain/discomfort/discharge.

-Colpexin Sphere is another nonsurgical device used. This intravaginal device is similar to a pessary, but it supports the pelvic floor muscles & facilitates exercise of these muscles & is removed daily for cleaning.


Surgical Mgmt for Pelvic Organ Prolaps of Cystocele? and Rectocele?

-Cystocele: Anterior Colporrhaphy, repair of anterior wall of vagina.

-Rectocele: Posterior Colporrhaphy.

-Perineorrhaphy, is repair of perineal lacerations.

These repairs are preformed laparoscopically, resulting in shorter hospital stays & good outcomes.

-Surgical Mesh has been used but is associated w/ erosion. pg.1660


What is a Uterine Prolapse? S/S?

-When structures that support the uterus weaken(usually in birth), the uterus may work its way down the vaginal canal(prolapse) & even appear outside the vaginal orifice(Procidentia). As the uterus descends, it may pull the vagina walls, bladder, & rectum w/ it.

-Pressure & urinary prob.(incontinence-retention) from displacement of bladder. Symptoms worse when woman coughs, lifts heavy objects, stands for a long time, walks up stairs.


What is Medical Mgmt for Uterine Prolapse?

Surgical options include the uterus being sutured back into place & repaired to strengthen/tighten the muscle bands.

-Hysterectomy or Colpopexy(suturing mesh to sacrum for uterine support)are options for postmenopausal women.

-Colpocleisis(vaginal closure-for woman not wanting to have sex or kids).

-Conservative tx such as: Pessaries(usually older woman or those who cant tolerate surgery),Kegel exercises, both together usually result in symptomatic improvements.


Nursing Mgmt. of Uterine Prolapse?


-Preventative Measures:
Kegel exercises, reporting any complications such as hemorrhoids, infections asap.

-Preoperative Nursing Care:
inform pt the extent of proposed surgery, expectations for postoperative period, & effect of surgery on future sexual function.
-Pt having a rectocele may need Laxative/Enema to be administered at hm prior.

-Postoperative Nursing Care:
Immediate post op goals are Preventing infect & pressure on any suture line.
-Pt is encouraged to void w/ in few hrs after CYSTOCELE & COMPLETE TEAR.
-If pt does not void & reports pain after 6 hours she needs to be catheterized. (Indwelling catheter may be indicated 2-4 days)
-If there is an incision clean peri/rectum w/ warm sterile saline & dried w. sterile absorbent material after voiding.

-After Complete Perineal Laceration, Bladder is drained through catheter to prevent strain on sutures. Stool softeners nightly after soft diet begins.

-Educating Pt. about self-care:
-Cleanliness, prevention of constipation, recommended exercises, avoiding lifting heavy objects or standing for prolonged periods.
-Instruct pt to report any pelvic pain, discharge, vaginal bleeding.
-Continue care w/: Kegel, keep follow up visits to see when safe to resume sex.


Therapeutic Interventions for Pelvic Organ Prolapse include?

-Surgical Correction
-Kegel Exercises
-Squeeze Pubococcygeal Muscle
-Hold 10secs
-Relax (10sec/book 57-4)
-Repeat 15x daily (30-80/book 57-4)


What are Ovarian Cysts? S/S

May be simple enlargements of normal ovarian constituents, the graafian follicle(fluid filled shell where egg ovum develops),or the corpus luteum(follicle shell filled w/ blood?)

-May also arise from abnormal growth of ovarian epithelium. Typically benign but should be evaluated mainly in postmenopausal woman.

-S/S Abdom pain. Symptoms of ruptured cyst mimic various acute abdominal emergencies such as:
-Ectopic preg
-Larger cyst may produce abdominal swelling & exert pressure on adjacent abdominal organs.


What is Polycystic Ovarian Syndrome (PCOS)? S/S?

Type of hormonal imbalance or cystic disorder that affects the ovaries. This complex endocrine cond. involves a disorder in the Hypothalamic-pituitary & ovarian network, resulting in chronic anovulation(no eggs are released during menses),and clinical adrogen excess, often along w/ multiple sm ovarian cysts.

-S/S: Obesity, insulin resistance, impaired glucose intolerance, dyslipidemia, sleep apnea, infertility.
-Symptoms are related to androgen excess. Cysts form in the ovaries because the hormonal milieu cannot cause ovulation on a reg basis.


How is Polycystic Ovarian Syndrome Diagnoses?

-Diag is based on clinical criteria, including hyperandrogenism, menstrual dysfunction, polycystic ovaries on ULTRASOUND EXAM. 2/3 criteria MUST be present to make diagnosis.

-Woman w/ PCOS are at increased risk for: diabetes, increased blood lipids, cardiovascular disease, Psychosocial issues including: Anger, frustration, anxiety.


Medical Mgmt of Polycystic Ovarian Syndrome?

-Surgical removal for Lg cysts.
-However oral contraceptives may be used in young, healthy pts to suppress ovarian activity & resolve sm cysts. that are fluid filled or physiologic.

-Lifestyle changes are critical: wt. loss of at least 5% of total body wt can help hormone imbalance/infertility. Metformin(Glucophage) often regulates periods/helps w/ wt loss.

-These woman are increased risk for ENDOMETRIAL CANCER, due to anovulation.


What are Benign Tumors of the Uterus:
Fibroids (Leiomyomas, Myomas)

-Fibroids arise from the muscle tissue of the uterus & can be solitary or multiple, in the lining(intracavity), muscle wall(intramural), outside surface(serosal) of the uterus.

-Develop slowly between 25-40yrs, may become quite lg. 10yrs prior to menopause fibroid may have a growth spurt poss. related to anovulatory cycles & high levels of unopposed Estrogen.

-Fibroids are common reasons for hysterectomy because they often result in Menorrhagia(heavy bleeding)which can be difficult to control.


S/S of Fibroid Tumors

-Irregular bleeding(menorrhagia-heavy)
-Pain from pressure on organs
-Fatigue d/t anemia


Medical Mgmt of Fibroids?

-Tx depends on: sz/symptoms/location/woman's age/reproductive plans.

-Fibroids usually shrink during menopause when ESTROGEN is no longer produced.

-Hormone suppression (they are Estrogen sensitive)
-leuprolide {Lupron} or other GONADOTROPIN-releasing hormone (GnRH) analogues, induce a temp menopauselike environment to shrink fibroids prior to surgery/alleviate anemia(frm heavy bld flow). Req monthly injections(hot flashes/vag dryness)short term tx cause can lead to bone density.

-Myomectomy(removes Lg tumors, leaves uterus for preg)

-Hysterectomy if severe pain or bleeding & no longer desire preg.


Several alternatives to Hysterectomy have been developed for the tx of excessive bleeding.

-Hysteroscopic resection of myomas: Laser passed through cervix-No incision/no overnight stay.

-Laparoscopic myomectomy: Laparoscope through sm abdominal incision.

-Laparoscopic myolysis: Cauterize & shrink w/ laser or electrical needles

-Laparoscopic cryomyolysis: Coagulate w/ electric current

-Uterine artery embolization: Polyvinyl alcohol or gelatin particles are injected into the blood vessels that supply fibroid via femoral artery result in infarction/shrinkage. This Percutaneous image-guided therapy offers an alternative to hormone therapy or surgery.
-However UAE may result in serous complications such as: pain, infection, amenorrhea(heavy bld), necrosis, Rare-death.

-Magnetic resonance-guided focused ultrasound surgery: Ultrasonic energy is passed through the abdom wall to target & destroy the fibroid, for those who dnt want anymore preg & is out pt procedure.


What is Endometriosis?

-Endometrial tissue outside the uterus.

-Chronic disease affecting 6-10% woman of reproductive age, consisting of benign lesions that contain endometrial tissue(similar to the lining of the uterus) found in the pelvic cavity outside the uterus.

-Extensive endometriosis may cause few symptoms, or isolated lesions may produce severe symptoms.

-Is the Major cause of pelvic pain & infertility.

-Higher Incidence Occur:
-Bearing children late in life/or fewer children.
-Woman whose close female relatives are affected.
-Shorter menses cycle(<27 days)
-Flow(>7 days)
-Younger age at menarche

-Countries where tradition favors early marriage/childbearing, endometriosis is rare.

-Characteristically, endometriosis is found in young, Nulliparous(no live preg past 20 wks) between 25-35yrs, particularly those with dysmenorrhea(painful menses)that does not respond to non-steroidal anti-inflammatory drugs or oral contraceptive agents.


Pathophysiology of Endometriosis?

Endometrial cells are carried to other parts of body via the blood & lymph nodes. Ovarian hormones initiate the cycle of cell sloughing(shedding/removing)in the uterus as well as those cells that have traveled to other parts of the body. Bleeding will then occur in the abdom. cavity causing pain, swelling, damage to abdom. organs & development of scar tissue.

-Thought to be caused by the backward flow of blood into the fallopian tubes & out to structures during menstruation.

-Each month ovaries produce hormones that stimulate the cells of the uterine lining(endometrium)to multiply & prepare for a fertilized egg. The lining swells and gets thicker. If these cells(endometrial cells) grow outside the uterus, endometriosis results. Unlike cells normally found in the uterus that are shed during menstruation, the ones outside the uterus stay in place. They sometimes bleed a little, but they heal & are stimulated again during the next cycle.

-The ongoing process leads to symptoms of endometriosis(pain), can cause scars(adhesions) on the tubes, ovaries, and surrounding structures in the pelvis.


Endometrial tissue contained within an ovarian cyst has no outlet for the bleeding; this formation is referred to as?

-Pseudocyst or Chocolate cyst.
-Adhesions, cysts, scar tissue may result, causing pain and infertility.


Causes of Endometriosis?

Unknown, but number of theories including:
-The endometrial cells loosened during menses may "back up" through the fallopian tubes into the pelvis. Once there, they implant/grow in pelvic or abdominal cavities(Retrograde menstruation). This happens in many woman, but there may be something diff about the immune system in those who develop endometriosis compared to those who do not.


Clinical Manifestation of Endometriosis?

-Dysmenorrhea(painful menses)
-Dyspareunia(painful sex)
-Dyschezia(pain w/ bowel movement)
-Radiation of pain to back or leg
-Depression, loss of work due to pain
-Relationship difficulties may result
-Infertility may occur from fibrosis/adhesions or because of a variety of substances(prostaglandins, cytokines(secreted by certain cells of immune system) produced by the implants of endometriosis and scar tissue on anatomical sites.


Assessment, Diagnostic Findings of Endometriosis?

-Health hx, menses pattern is necessary to elicit specific symptoms.
-Laparoscopic exam confirms diagnosis & helps stage the disease.
-Stage 1: pt have superficial or minimal lesions.
-Stage 2: mild involvement.
-Stage 3: moderate involvement.
-Stage 4: Extensive involvement & dense adhesions w/ obliteration(destruction) of the cul-de-sac(dead end).


Medical Mgmt for Endometriosis?

-Tx depends on symptoms, pts desire for preg, extent of disease.

-Mild symptoms, may only req exams q 6-12 mo. Managing symptoms by exercise & relaxation.

Non steroidal anti-inflammatory drugs (NSAIDs):
-Tylenol, Rx painkillers for cramping.

Hormone Medications:
-Estrogen & Progesterone(birth control) stops Menstrual Cycle, creating a state resembling preg(pseudopregnancy), relieves most symptoms, dnt prevent scarring or reverse physical damage.

-Progesterone pill/injection, S/E wt.gain/spotting.

-Gonadotropin Agonist drugs: Stop ovaries from producing estrogen:
-Nafarelin acetate(Synarel)& Depo Lupron.
S/E: menopausal symp, hot flashes, vag dryness, mood changes, early loss of calcium frm bones.
Due to: Bone density loss this type of tx is usually limited to 6mo. 1yr if sm doses of estrogen & progesterone are given to reduce bone weakening.

-Hormonal meds are short term & NOT USED in pt w/ hx of abnormal vag bleeding or liver, heart, kidney disease.

Surgery for severe pain not improving w/ hormone tx or want preg now/future:
-Laparotomy(surgical incision) to diag endometriosis, remove/destroy all of endometriosis related tissue/scar tissue(adhesions).
-Hysterectomy(remove uterus) for severe sympt/dnt want preg.


Preoperative Mgmt?
Postoperative Mgmt?

-Supracervical or subtotal: only uterus, cervix is spared.

-Discontinue anticoagulants NSAIDs(aspirin), Vit-E.
-Prophylactic antibiotics prior, disc. next day.
-Prevention of thromboembolic events is critical(methods depend on risk profile of pt)

-Principles of general postop for abdom surgery.
-Major risks are infect/Hemorrhage.
-Due to surgical site being close to bladder, voiding prob may occur.
-Edema or nerve trauma may cause temp. loss of bladder tone(bladder atony)requiring an indwelling catheter.


Nursing Process Hysterectomy?
Assessment for pt undergoing Hysterectomy?

-Health hx
-Physical & pelvic exam
-Lab tests
-Pt psychosocial responses (need for surgery may elicit strong emotional reactions).
-If surgery to remove tumor, pt may have Anxiety, related to fear of cancer.


Nursing Diagnosis for Hysterectomy?

-Disturbed body image
-Acute pain
-Deficient knowledge of the perioperative aspects of hysterectomy and postoperative self-care.


Potential Complications w/ Hysterectomy?

Count pads used/check incision site, assess extent of saturation w/ blood, monitor vitals.

-DVT and PE:
Due to positioning during surgery, postoperative edema, & decreased activity. Pt wears stockings, change positions freq, Although PRESSURE UNDER THE KNEES IS AVOIDED, and exercise legs/feet in bed.


Discharge hm soon: Avoid prolonged sitting in chair w/ pressure on knees, legs crossed, and inactivity.

-Bladder dysfunction:
Indwelling catheter until able to ambulate. Monitor output, abdomen for distention. If pt doesn't void w/in prescribed time initiate measures: assisting to restroom, warm water over perineum. Poss catheter reinsertion.

Post-operation instructions/limitations, check site daily, contact PCP (red, purulent drainage).

-Pt teaching: inform pt periods are over but may have bloody discharge for few days, if bleeding recurs call PCP asap.
Important to maintain bowel/urinary function.

Avoid: Sitting long time(cause blood pooling in pelvis ^ risk for VTE(venous thromboembolism), AVOID Baths(infection),Straining, lifting, sex, driving.

Report: Vag discharge, foul oder, excessive bleeding, leg redness/pain/^temp.


Nursing Mgmt of Endometriosis?
Pt Goals?
Pt Teaching?

-Health hx, physical exam focus on:
-Specific symptoms(pelvic pain)
-Medication effects
-Reproductive plans

Pt Goals include relief of:
-Dysmenorrhea(painful menses)
-Dyspareunia(painful sex)
-Avoidance of infertility

Pt Teaching:
-Dispel myths & encourage pt to seek care if dysmenorrhea/dyspareunia occurs.