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Chapter 13 – Women's Health and Gynecology

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Chapter 13 – Women's Health and Gynecology chapter 13 – WOMeN’S heaLth aND GYNecOLOGY First Nations and Inuit Health Branch (FNIHB) Clinical Practice Guidelines for Nurses in Primary Care. The content of this chapter has been reviewed June 2010. table of contents Assessment of the femALe RePRoDUCtIVe sYstem ............................13–1 history of Present Illness and Review of systems ...........................................13–1 examination of the female Reproductive system .........................................13–2 Cervical Cancer screening ..............................................................................13–3 Common Women’s heALth IssUes AnD GYneCoLoGICAL PRoBLems ...................................................................13–4 Abnormal Uterine Bleeding ..............................................................................13–4 Dysfunctional Uterine Bleeding (DUB) .............................................................13–5 Dysmenorrhea .................................................................................................13–9 Breast Lumps .................................................................................................13–11 mastitis ...........................................................................................................13–11 human Papillomavirus (Genital Warts) ..........................................................13–13 Contraception .................................................................................................13–15 emergency oral Contraception ......................................................................13–18 menopause ....................................................................................................13–20 GYneCoLoGICAL emeRGenCIes ...................................................................13–22 Acute Pelvic Pain of Gynecological origin ....................................................13–22 Pelvic Inflammatory Disease (PID) ................................................................13–23 soURCes ............................................................................................................13–26 Clinical Practice Guidelines for Nurses in Primary Care 2010 Women’s Health and Gynecology 13–1 aSSeSSMeNt Of the feMaLe reprODUctive SYSteM hiStOrY Of preSeNt iLLNeSS Obstetric History aND revieW Of SYSteMS – Number of pregnancies, live deliveries, stillbirths, abortions (spontaneous, therapeutic) GeNeraL – Difficulties with pregnancies, deliveries The following characteristics of each symptom should – Birth weight of babies be elicited and explored: – History of substance use – Onset (sudden or gradual) Use of Contraception – Chronology – Current situation (improving or deteriorating) – Type used (past and present) – Location – Difficulties with method, suitability – Radiation – If discontinued, reasons for doing so – Quality Sexual History – Timing (frequency, duration) – Sexual orientation – Severity – Regularity of intercourse – Precipitating and aggravating factors (for example, – Number of partners in the past 12 months medication use) – Associated symptoms (for example, pain, – Relieving factors postcoital bleeding) – Associated symptoms (such as fever) – Sexual dysfunction – Effects on daily activities – Sexual habits and practices – Previous diagnosis of similar episodes – Previous treatments Breasts – Efficacy of previous treatments – Soreness, tenderness and their relation to menstrual – Sexual activity cycle – Possibility of pregnancy – Redness, swelling, nipple discharge carDiNaL SYMptOMS – Change in contour, presence of masses – Is client breast-feeding? In addition to the general characteristics outlined above, additional characteristics of specific symptoms Lymphatic System should be elicited, as follows: – Enlarged, painful nodes (in axillae, groin) Menstrual History Vaginal Discharge – Age at menarche – Onset, colour, odour, consistency, quantity – Interval, regularity, duration and amount of flow – Relation to menstrual period – Date of most recent menstrual period – Associated symptoms (for example, rectal or – Was most recent menstrual period normal? urethral discharge, vaginal itch or burning, urinary – Dysmenorrhea symptoms, malaise, abdominal pain, fever) – Premenstrual symptoms (for example, swelling, – Relation to medication use (for example, headache, mood swings, pain) antibiotics, steroids) – Abnormal uterine bleeding – History of previous vaginal or pelvic infections and – Symptoms of menopause their treatment – Age at menopause – Postmenopausal bleeding – Use of tampons Clinical Practice Guidelines for Nurses in Primary Care 2010 13–2 Women’s Health and Gynecology Pain BreaStS – Onset, location, radiation, character, severity – Inspect breasts with client in sitting and then in – Relation to menstruation supine position – Aggravating and relieving factors – Assess symmetry, contour, skin colour, thickening, – Use of analgesics and their effect dimpling or retraction of overlying skin, veins, – Associated gastrointestinal, urinary or vaginal redness, streaking symptoms – Examine nipples for symmetry, discharge, erosion, – Are pain symptoms related to sexual activity? crusting, colour – Palpate breasts and axillae for consistency, Other Associated Symptoms tenderness, masses – Ulcerations – Encourage women to know what is normal for them, to be informed of early symptoms of breast – Persistent lesions cancer, and to promptly report any changes or – Sense of pelvic relaxation (pelvic organs feel as concerns though they are falling down or out) – Encourage screening mammography every 1–2 – Infertility years for women 50–69 years of age (earlier for – Pelvic infection women with risk factors and screening prevalence) Breast self-examination teaching tools: exaMiNatiON Of the feMaLe reprODUctive SYSteM – An on-line demonstration of breast self- examination can be found at: http://www. GeNeraL breastselfexam.ca/index.html – The Peter Ballantyne Cree Nation Health – Apparent state of health Services produced a DVD in 2008 titled: – Appearance of comfort or distress Nanakatawithimino (Take Care of Yourself). – Colour (for example, flushed or pale) It presents women of First Nations’ perspective – Nutritional status (obese or emaciated) of mammograms and Pap tests. Copies can – Match between appearance and stated age be requested via the nursing clerk at: pcuster. [email protected] or (306) 953-4425. VITAL SiGNS LYMph NODeS – Temperature – Pulse Palpate the following areas and identify enlargement, – Respiratory rate tenderness, mobility and consistency: – Blood pressure – Upper extremity: supraclavicular area, – Weight (to establish a baseline) infraclavicular area, axillae, epitrochlear nodes – Height (to establish a baseline) – Lower extremity: inguinal nodes exterNaL GeNITALia – Distribution of hair – Labia majora and labia minora: lesions, ulcerations, masses, induration, areas of different colour – Clitoris: size, lesions, ulcerations – Urethra: discharge, lesions, ulcerations – Skene’s and Bartholin’s glands: masses, discharge, tenderness – Perineum: lesions, ulcerations, masses, induration, scars – Anus: lesions, ulcerations, tenderness, fissures, hemorrhoids 2010 Clinical Practice Guidelines for Nurses in Primary Care Women’s Health and Gynecology 13–3 VAGiNa cervicaL caNcer ScreeNiNG – Inflammation Guidelines for cervical cancer screening vary from – Atrophy one jurisdiction to another. Since cervical cancer – Discharge is more common among Aboriginal women than – Lesions, ulcerations, excoriation non-Aboriginal women and that screening rates are – Masses substantially lower among First Nations women – Induration or nodularity than among other Canadian women, the following guidelines can serve as a baseline.1,2 – Relaxation of perineum (ask client to bear down and observe for any bulging of vaginal walls) – Screening should occur once a woman is sexually active CERVIX – Annual Papanicolaou (Pap) test for all women with – Position, colour, shape, size, consistency multiple partners – Discharge – Screen annually until there are 3 negative Pap – Erosions, ulcerations results then continue every 2–3 years thereafter – Cervical tenderness – Women who have never had a Pap test, or who – Bleeding after contact have not been screened for over 5 years, should have 3 Pap tests, 1 year apart. If the results of tests Consistency of cervical tissue: normal cervix is pink are normal, testing can occur every 3 years and feels firm, like the tip of the nose; in pregnancy, – Women over the age of 67 years, with no Pap test the cervix is bluish and feels softer, like the lips of the for the last 3 years, should be tested at 6-month mouth. intervals for a year. If the results of both tests are UterUS normal, further testing may not be required – Women with a total hysterectomy may still require – Position regular Pap tests. This should be discussed with the – Size treating physician or nurse practitioner – Contour – Women require regular testing until age 75 if there – Consistency of uterine tissue is an adequate negative screening history in the – Mobility previous 10 years (i.e., 3–4 negative tests) – Pain on movement For instructional materials on Pap tests, consider the Alberta Cancer Board’s RN Pap test Learning aDNexa Module: 2009. Nurses in the Alberta region have Ovaries cannot usually be felt unless the client is very access to the electronic version on-line. thin or the ovaries are enlarged. Other regions may request a copy by contacting the – Tenderness Alberta Health Services
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