Lecture Sixteen: Care of the Client Experiencing Reproductive Dysfunctions

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Lecture Sixteen Care of the Client Experiencing
Reproductive Dysfunctions

• NURS 2208
• Fall 2002
• T. Dennis RNC, MSN

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Reproductive Dysfunctions

• Discuss the female menstrual and reproductive
  cycles.
• Identify common terms associated with
  reproductive dysfunctions.
• Discuss the clinical manifestations and
  therapeutic management of reproductive
  dysfunctions.

• Identify data to be included in the assessment of
  a client with reproductive disorders.
• Formulate appropriate nursing diagnoses.
• Select appropriate nursing interventions for a
  woman with reproductive dysfunction.

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Education

• Nurses should provide girls and women with clear
  information about menstrual issues, such as use
  of pads and tampons (including warnings regarding
  deodorant and absorbency) vaginal spray and
  douching practices self-care comfort measures
  during menstruation, such as maintaining good
  nutrition, exercising, and applying heat and
  massage.

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Menstruation (pg.40)

• Menarche Beginning of menstrual and reproductive
  function in the female. Average age 12 years.
• Menstrual cycle cyclic buildup of the uterine
  lining, ovulation, and sloughing of the lining
  occurring approximately every 28 days in
  non-pregnant females.
• Menorrhagia Excessive or profuse menstrual flow.
• Hygiene Tampons (change frequently regardless of
  blood flow), pads (change frequently), vaginal
  sprays (unnecessary and may cause irritation) and
  douching (sometimes used to treat vaginal
  infections but contraindicated for hygiene
  purposes, may contribute to endometriosis).

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Amenorrhea (pg. 42)

• Suppression or absence of menstruation.
• Primary 1) occurs when menstruation has not
  been established by age 18. 2) may be
  caused by congenital anomalies, or absence or
  imbalance of hormones.
• Secondary 1) occurs when an established menses
  of 3 months ceases. 2) common causes pregnancy,
  lactation, hormonal imbalances, poor nutrition,
  stressful life events, etc.
• Treatment is dictated by causative factors. Once
  the underlying factors have been addressed,
  menses returns to the normal pattern.

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Dysmenorrhea

• Usually begins at or a day before, the onset of
  menses and disappears by the end.
• Treatment Hormone therapy (eg., oral
  contraceptives), nonsteroidal anti-inflammatory
  drugs, or prostaglandin inhibitors (ibuprofen,
  aspirin, naproxen) can alleviate dysmenorrhea.
• Primary cramps without underlying disease
  process.
• Secondary associated with pathology of the
  reproductive tract and usually appears after
  menstruation has been established. Includes
  endometriosis, pelvic inflammatory disease (PID),
  
• Self-care measures include improving nutrition,
  exercising, applying heat, and getting extra
  rest. Avoid salt intake during menstruation, use
  a heating pad on the abdomen, daily exercise such
  as walking.

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Premenstrual Syndrome (PMS) (pg. 43)

• Occurs most often in women over thirty.
• Symptoms include irritability, depression,
  migraines, vertigo, rhinitis, nausea, vomiting,
  abdominal bloating, urinary retention, acne,
  weight gain, and mammary swelling and tenderness.
• Symptoms occur 2 to 3 days before the onset of
  menstruation and subside as menstruation starts,
  with or without treatment.
• Medical management usually includes progesterone
  agonists and prostaglandin inhibitors.
• Self-care measures include improving nutrition
  (taking vitamin B complex (especially B6) and E
  supplements), and avoiding methylxanthines, found
  in chocolate and caffeine, undertaking a program
  of aerobic exercise, and participating in
  self-care support groups.

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Menopause (pg. 58-60)

• The time when menses cease.
• Current median age is 51.3 years but may occur
  between ages 45 to 52.
• Perimenopause a normal life transition that
  begins with the first signs of change in the
  menstrual cycles and ends 6 to 12 months after
  menopause.
• Perimenopause is marked by irregular menstrual
  cycles and hot flashes, shorter and lighter
  menses, occasional missed periods, abnormal FSH
  levels, increased vaginal dryness, and night
  sweats.
• Menopause is the single day that marks the last
  naturally occurring menstrual period. The date is
  determined in retrospect one year from the last
  period. So contraception must be used for that
  year.

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Menopause (pg. 58-60)

• Psychological aspects
• Menopause in the past has had a negative
  connotation.
• New research and treatments have diminished some
  negative aspects.
• Physical aspects
• Age of onset may be influenced by overall health,
  nutritional, cultural, lifestyle and genetic
  factors.
• Onset occurs when estrogen levels become so low
  menstruation stops.
• Generally ovulation stops 1 to 2 years before
  menopause.
• 2 to 4 years prior to menopause changes in cycles
  may occur.
• Uterine endometrium, myometrium, cervical glands,
  fallopian tubes and ovaries atrophy.
• A vasomotor disturbance known as hot flashes
  occurs.

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Menopause (pg. 58-60)

• Long range physical changes include Osteoporosis.
• Osteoporosis is a decrease in bony skeletal mass.
• Associated with decreased estrogen levels causing
  imbalances in bone formation and resorption.
• Weight gain
• Increased risks for coronary artery disease,
  hypertension, and strokes.

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Menopause (pg. 58-60)

• Medical Therapy may include Hormone replacement
  therapy (HRT) administration of hormones,
  usually estrogen and progestin, to alleviate the
  symptoms of menopause.
• Benefits
• Stops hot flashes and night sweats
• ? incidence of coronary artery disease
• Prevention and treatment of bone loss
• Improved bladder and vaginal tone
• May improve memory
• Risks
• ? risk of gallbladder disease, venous thrombosis,
  endometrial cancer, breast cancer and systemic
  Lupus
• Dosage
• Estrogen is given the first 25 days of the month
  then progestin is added during the last twelve
  days.

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Menopause (pg. 58-60)

• Prevention and treatment of osteoporosis
• Prevention is the primary goal of care.
• Calcium intake of 1200 to 1500 mg per day for
  clients gt 50 years of age.
• Calcium supplements are most efficient when taken
  with a meal and when single doses do not exceed
  500mg.
• Participation in regular exercise program.
• Fosamax (alendronate) inhibits bone resorption
  and increases bone mass. Recommended for women
  who cannot take estrogen. Must be taken on an
  empty stomach with water at least 30 minutes
  before any other fluid, food or medicine.

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Menopause (pg. 58-60)

• Alternative and Complementary Therapies
• Diet rich in calcium and vitamins, E, D, and B
  complex.
• Phytoestrogens include carrots, yams and soy
  products.
• Avoid caffeine, alcohol and spicy foods.
• Begin weight bearing exercise walking, jogging,
  running.
• Practice relaxation techniques
• Herbal remedies may include ginseng to relieve
  symptoms of hot flashes, headaches and fatigue.
• Keeping a cool environment and drinking cool
  fluids may alleviate hot flashes.
• Kegel exercises are important in maintaining
  vaginal and bladder tone.
• Vaginal lubricants may alleviate vaginal dryness
  (decreased libido may occur).

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Endometriosis (pg. 63)

• Condition characterized by the presence of
  endometrial tissue outside the uterine cavity.
• Can be found in the vagina, lungs, cervix,
  central nervous system and GI tract.
• Most common location is the pelvis.
• Tissue responds to the hormonal changes of the
  menstrual cycle and bleeds in a cyclic fashion.
• Results in inflammation, scarring of the
  peritoneum, and formation of adhesions.
• Most common symptom of endometriosis is pelvic
  pain.

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Endometriosis (pg. 63)

• Treatment
• Medical, surgical intervention or both.
• Laser vaporization under laparoscopic
  examination.
• Hysterectomy with bilateral salpingo-oophorectomy.
  
• Mild disease NSAIDS and analgesics.
• Other medications include oral contraceptives,
  progestins, antiprogestins, and
  gonadotrophin-releasing hormones (GnRH).
• Danazol is an antiprogesterone treatment that is
  frequently used suppresses GnRH which suppresses
  ovulation and causes amenorrhea. Side effects
  include hirsutism, acne, weight gain and vaginal
  bleeding.

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Danazol

• Danacrine 400 mg po bid
• Therapeutic classification Hormones
• Pregnancy category X
• Indication Treatment of moderate endometriosis
  that is unresponsive to conventional therapy.
• Adverse reactions amenorrhea, weight gain, voice
  changes, decreased breast size.
• Caution Pregnancy should be avoided while on
  this medication.

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Endometriosis (pg. 63)

• Nursing Assessment
• Thorough history
• Understanding of condition
• Diagnosis
• Pain related to peritoneal irritation secondary
  to endometriosis
• Ineffective Individual Coping related to
  depression secondary to infertility.

• Nursing Plan
• Explain condition, symptoms, treatment
  alternatives, and prognosis.
• Review medication knowledge.
• Review need to make choices considering not
  postponing pregnancy.
• Support the client by being nonjudgmental.

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Toxic Shock Syndrome (pg. 64)

• Associated with the use of super-absorbent
  tampons.
• Causative organism is staphylococcus aureus.
• Common signs fever, desquamation of skin
  (especially the palms of hands and soles of
  feet), rash, hypotension, dizziness, vomiting,
  diarrhea, and disorders of the central nervous
  system.
• Treatment includes hospitalization with
  supportive therapy including intravenous therapy
  to maintain blood pressure. Severe cases may
  require renal dialysis, administration of
  vasopressors, and intubation.
• Education Change tampons every 3 to 6 hours and
  avoid use of super-absorbent tampons. Alternate
  tampons and pads and use only pads overnight.

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Pelvic Inflammatory Disease (PID) (pg. 72)

• An infection of the fallopian tubes (salpingitis)
  that may or may not be accompanied by a pelvic
  abscess may cause infertility secondary to
  tubal damage.
• Disease is more common in women who have had
  multiple sexual partners, a history of PID, early
  onset of sexual activity, a recent gynecologic
  procedure, or an intrauterine device.
• Causative organisms include Chlamydia
  trachomatis and neisseria gonorrhoeae.
• Symptoms include bilateral sharp cramping pain
  in the lower quadrants, fever, chills, purulent
  vaginal discharge, irregular bleeding, malaise,
  nausea, and vomiting.
• Possible to be asymptomatic and have normal lab
  values.

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Pelvic Inflammatory Disease (PID) (pg. 72)

• Clinical therapy
• Diagnosis consists of a clinical examination to
  define symptoms, blood tests, and culture for
  Chlamydia and GC.
• Direst abdominal tenderness with palpation,
  adnexal tenderness, and cervical and uterine
  tenderness with movement.
• Laparoscopy may be used to obtain cultures and
  confirm diagnosis.
• Hospitalization with intravenous administration
  of antibiotics.
• Sexual partner should also be treated.

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Pelvic Inflammatory Disease (PID) (pg. 72)

• Nursing Assessment
• Thorough history (IUD)
• Alert to risk factors for condition
• Symptoms of lower abdominal pain, malaise, foul
  smelling discharge
• Diagnosis
• Pain related to peritoneal irritation
• Knowledge deficit related to lack of information
  about possible infertility

• Nursing Plan
• Explain condition, symptoms, treatment
  alternatives, and prognosis.
• Review medication knowledge.
• Discuss signs and symptoms of PID and stresses
  the importance of early detection.
• Support the client by being nonjudgmental.

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Abnormal Uterine Bleeding (pg.74)

• Dysfunctional uterine bleeding (DUB)
  characterized by anovulatory cycles with abnormal
  uterine bleeding that does not have an
  identifiable cause.
• Oligomenorrhea scanty or infrequent menstrual
  flow
• Polymenorrhea occurring with abnormal frequency
• Menorrhagia excessive bleeding
• Metrorrhagia spotting or breakthrough bleeding
• Menometrorrhagia irregular and excessive
  menstrual flow
• Intermenstrual bleeding bleeding between menses

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Abnormal Uterine Bleeding (pg.74)

• Diagnosis is made by excluding organic causes
• Lab tests Pap smear, thyroid function studies,
  pregnancy test and possible endometrial biopsy.
• Goals of treatment control bleeding, prevent or
  treat anemia, prevent endometrial hyperplasia or
  cancer, and restore quality of life.
• Pharmacologic treatment for women desiring
  pregnancy includes clomiphene citrate or
  gonadotrophins to induce ovulation.
• Reproductive tract diseases that cause bleeding
  problems include Abnormal pregnancy (threatened,
  missed or incomplete abortion, ectopic
  pregnancy), 2) Endometrial, cervical , or ovarian
  cancer, 3) Uterine lesions (fibroids, polyps,
  adenomyosis), 4) Cervical lesions (polyps,
  cervicitis, herpes, or chlamydia.

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Ovarian Masses (pg. 74)

• Between 70 to 80 of ovarian masses are benign.
• No relationship exists between ovarian masses and
  ovarian cancer.
• Symptoms sensation of fullness or cramping in
  the lower abdomen, dyspareunia (painful sexual
  intercourse), irregular bleeding, or delayed
  menstruation. May be asymptomatic and mass noted
  on routine pelvic exam.
• Diagnosis made on the basis of a palpable mass
  with or without tenderness and other related
  symptoms.
• Clinical management observation for a month or
  two (most cysts will resolve and are harmless),
  oral contraceptives may be prescribed to suppress
  ovarian function, A repeat pelvic exam is done to
  determine effectiveness of treatment.
• Surgery is not always necessary.

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Uterine Masses (pg. 75)

• Fibroid tumors (leiomyomas) are among the most
  common benign disease entities affecting women.
• Develop when smooth muscle cells are present in
  whorls and arise from uterine muscle and
  connective tissue.
• Size varies from 1 to 2 cms to size of a ten week
  fetus.
• Client is frequently asymptomatic.
• Symptoms include lower abdominal pain, fullness
  or pressure, menorrhagia, metrorrhagia, or
  increased dysmenorrhea. May be palpated on pelvic
  exam.
• Ultrasound can assist and confirm diagnosis.
• Initial treatment increase the frequency of
  pelvic exams to every 3 to 6 months.
• Treatment if mass is increasing in size or
  symptoms surgery (myomectomy, DC,
  hysterectomy). Majority of these masses require
  no treatment and will shrink after menopause.

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Endometrial Cancer (pg. 75)

• Most commonly a disease of the postmenopausal
  client.
• Hallmark sign vaginal bleeding in postmenopausal
  women not treated with hormone replacement
  therapy.
• Diagnosis made by endometrial biopsy or
  post-hysterectomy pathologic examination of the
  uterus.
• Treatment Total Abdominal Hysterectomy (TAH) and
  bilateral salpingo-oophorectomy. Radiation
  therapy may be indicated, depending on the
  staging of the cancer.
• TAH or TVH Discharge teaching should include 1)
  no menstruation will occur, 2) Intercourse should
  be avoided for 4 to 6 weeks, 3) may be temporary
  loss of vaginal sensation if TVH, 4) heavy
  lifting should be avoided for 2 months.

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Ovarian Cancer (pg. 1543)

• Causes more deaths than any other cancer of the
  female reproductive system due to advanced
  disease process at diagnosis.
• Occurs more frequently in women between 55 and 65
  years old.
• Risk factors family history, increasing age and
  high fat diet.
• Risk reducing factors Breast feeding, multiple
  pregnancies, oral contraceptive use, and early
  age at first birth.
• Clinical manifestations usually asymptomatic in
  early stages, increased abdominal girth, bowel
  and bladder dysfunction, pain, menstrual
  irregularities, and ascites. Classified as Stage
  I, II, and III.
• Treatment total abdominal hysterectomy,
  chemotherapy, and radiation.

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Cervical Cancer (pg. 1540)

• An increased risk of cervical cancer is
  associated with low economic status, early sexual
  activity (before 17), multiple sexual partners,
  infection with HPV (human papilloma virus), and
  smoking.
• Widespread use of the Pap test is attributed with
  the decrease in cervical cancer over the past 40
  years.
• Progression from normal cervical cells to
  dysplasia and on to cervical cancer appears to be
  related to repeated injuries to the cervix.
• Clinical manifestations may be asymptomatic,
  leukorrhea, intermenstrual bleeding. Classified
  as Class I,II, III, IV, and V.
• Diagnosis pap test, colposcopy, and biopsy.
• Treatment repeat Pap test, laser, cautery,
  cryosurgery, surgery, radiation. (Pap smears and
  pelvic exams should be preformed annually
  beginning at age 18 or when sexually active.)

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Pelvic Relaxation (pg. 77)

• Cystocele the downward displacement of the
  bladder, which appears as a bulge in the anterior
  vaginal wall. Classified as mild to severe.
  Corrected surgically with an anterior
  colporrhaphy.
• Rectocele weakening between the rectum and
  vagina. Corrected surgically with a posterior
  colporrhaphy.
• Contributing factors include childbearing,
  obesity, genetic predisposition and increased
  age.
• Symptoms stress incontinence, loss of urine when
  coughing, sneezing, laughing or sudden exertion.
  Vaginal fullness, a bulging out of the vaginal
  wall, and/or a dragging sensation. May have to
  push upward vaginally to be able to urinate
  completely.
• Treatment Kegel exercises, estrogen improves
  condition of vaginal mucous membrane, vaginal
  pessary may be used if surgery is no indicated.
• Pessary a device inserted into the vagina to
  function as a supportive structure for the uterus.

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Uterine Prolapse (pg. 1548)

• The downward displacement of the uterus into the
  vaginal canal.
• Rated by degrees 1) First degree cervix rests
  in the lower part of the vagina, 2) Second
  degree cervix is at the vaginal opening, 3)
  Third Degree uterus protrudes through the
  introitus.
• Symptoms a feeling of something coming down,
  dyspareunia, backache, bowel or bladder problems,
  stress incontinence and tissue irritation to the
  protruding cervix.
• Therapy Kegel exercises, pessary, surgery
  (vaginal hysterectomy with an anterior and
  posterior repair).

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Questions?