Adult Health II Notes
Adult Health II Notes NSG 3336
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Ch. 49: Female Reproductive System AH2 Exam 5 Chapter 49: Female Reproductive System Uterus Muscular, hollow, pear‐shaped Walls: perimetrium, myometrium, endometrium Divisions: fundus, body, cervix Internal os, external os Usually anteflexed over the bladder Disorders of the Female Reproductive Tract Hormonal and Menstrual Alterations Infection and Inflammation Pelvic Relaxation Disorders Benign growths and proliferative disorders Cancer Hormonal and Menstrual Alterations Primary Dysmenorrheal Painful menstruation associated with ovulatory cycle but not associated with pelvic disease Excess prostaglandin production (10X) Increase myometrial contractions, constrict endometrial blood vessels causing ischemia, bleeding, and pain S/S: pain, backache, N/V/D, syncope, H/A TX: oral contraceptives, prostaglandin inhibitors, heating pad, diet low in fat, exercise Primary Amenorrhea Failure of menarche and absence of menstruation by age 14 without development of secondary sex characteristics or by age 16 regardless of presence of secondary sex characteristics Causes: congenital defects of gonadotropin production, genetic disorders, congenital CNS defects, anatomic defects Cause determines whether secondary sex characteristics and height are affected Secondary Amenorrhea Absence of menstruation for a time equivalent to 3 or more cycles or 6 months in women who have previously menstruated Causes: diseases, dramatic weight loss, stress, major trauma, new contraceptive Normal during early adolescence, pregnancy, lactation and near menopause, surgical menopause (hysterectomy) Abnormal Menstrual Bleeding Polymenorrhea‐ cycle <3 weeks Oligomenorrhea‐ cycle >6‐7 weeks Metrorrhagia‐ intermenstrual bleeding Hypermenorrhea‐ excessive flow Menorrhea‐ prolonged duration of flow Menorrhagia‐ increased amount and duration of flow Menometrorrhagia‐ prolonged flow with irregular and intermittent spotting between bleeding episodes Dysfunctional Uterine Bleeding 1 Ch. 49: Female Reproductive System AH2 Exam 5 (DUB) most commonly associated with anovulatory menstrual cycles Result of progesterone deficiency or estrogen excess. Estrogen stimulates proliferation and hyperplasia of endometrial glands Polycystic Ovary (PCO) Persistent anovulation with many etiologies and clinical manifestations Most common cause‐ inappropriate gonadotropin secretion excessive production of androgen and estrogen leads to excess accumulation of follicular tissue S/S: dysfunctional bleeding or amenorrhea, hirsutism, infertility Can be up to 810 cysts on ovaries when the rupture causes intense pain and peritonitis can result Increased risk for type 2 DM, breast cancer, and endometrial cancer Tx: BC pills, maintain normal weight, diets—refrain from caffeine Premenstrual Syndrome (PMS) Cyclic recurrence (in the luteal phase of the menstrual cycle) of physical, psychological, or behavioral changes distressing enough to impair interpersonal relationships and interfere with normal activities More than 200 physical, emotional, and behavioral symptoms have been attributed to PMS TX: individual, marriage, family counseling, anger management and stress reduction, regular exercise; adequate rest, time management; dietary changes‐ 6 small meals/day; increase complex CHO intake, fiber and water; decrease caffeine, alcohol, sugar, and animal fat consumption, decrease sodium Meds: antiprostaglandins, oral contraceptives, medroxyprogesterone, antidepressants (SSRIs, Zoloft, Paxil), NSAIDs Herbal remedies: ginger, bread clover Premenstrual Dysphoric Disorder (PMDD) Used by psychiatrists and other mental health workers to describe a specific set of mood symptoms that are present the week before menses and remit a few days after the start of menses and also interfere with social or role functioning. Most health care provides believe that PMS and PMDD refer to the same clinical entity. Basis for using antidepressants in treatment—Zoloft and Paxil used more for PMDD than PMS Infection and Inflammation Pelvic Inflammatory Disease o Acute inflammatory process involving any part of the upper genital tract: oophoritis‐ ovaries, salpingitis‐ fallopian tubes o Polymicrobial infection, cervicitis often precedes o May be asymptomatic or present with sudden severe pain, low bilateral abdominal pain, worse with movement, N/V, heavy purulent vaginal discharge Vaginitis o Causes: sexually transmitted pathogens and Candida albicans (cottage cheese look) o Normal ph is acidic, variables that alter ph or bactericidal nature of secretions predispose to infections o These all alter the ph—douching, soaps, hygiene sprays, deodorant pads or tampons, pregnancy, DM o Trichomonas, bacterial, candida albicans 2 Ch. 49: Female Reproductive System AH2 Exam 5 Cervicitis o Mucopurulent cervicitis usually caused by one or more sexually transmitted pathogens: trichomoniasis, gonorrhea, chlamydia, mycoplasma, o Cervix red and edematous o Discharge cultured or identified by o Pain with sex, movement, pressure o Treat partner also Vulvitis o Inflammation of vulva and often the perianal area o Causes: vaginal infections, soaps, detergents, lotions, hygienic sprays, menstrual pads, perfumed toilet paper, or non‐absorbent (non‐cotton) or tight‐fitting clothes Bartholinitis o Bartholin cyst: inflammation of one or both of the ducts that lead from introitus to bartholin glands o Causes: staph, strep, sexually transmitted pathogens o Cyst reddened and painful, pus may be visible at duct opening, most are asymptomatic Nursing care for all of these: o Look at culture and sensitivity o Teach pt. To finish all antibiotics o Fix their issues with painful urination o Increase fluid intake to 3 l or more a day o Wear cotton underwear and avoid douching Uterine Relaxation Disorders Uterine prolapse: falling or sliding of the womb (uterus) from its normal position into the vaginal area Cystocele: occurs when the tough fibrous wall between a woman's bladder and her vagina (the pubocervical fascia) is torn by childbirth, allowing the bladder to herniate into the vagina Urethrocele: the prolapse of the female urethra into the vagina Cystourethrocele: Urethroceles often occur with cystoceles, (involving the urinary bladder as well as the urethra). In this case, the term used is cystourethrocele Rectocele: bulging of the front wall of the rectum into the back wall of the vagina Benign Growth and Proliferative Disorders Benign ovarian cysts o Follicular cysts develop from a dominant ovarian follicle that does not release its ovum, but remains active or from a degenerating follicle whose fluid is not reabsorbed, often asymptomatic o Corpus luteum cyst mature corpus luteum persists abnormally and continues to secrete progesterone o S/S: dull pelvic pain, amenorrhea or delayed menstruation. Rupture can cause massive bleedinghypovolemia symptoms Endometrial polyps o Benign mass of endometrial tissue attached to inner endometrial lining by a pedicle o They look like grapelike growths (similar to appearance of nasal polyps) o Cause premenstrual or intermenstrual bleeding in premenopausal woman, malignancy extremely rare 3 Ch. 49: Female Reproductive System AH2 Exam 5 o Causes painful sex **Leiomyomas (Uterine Fibroids)** LOOK OVER MORE IN BOOK o Develop from smooth muscle in myometrium; genetic o Most common benign tumors of uterus, usually remain small and asymptomatic o Often occur in multiples in fundus o Risk Factors: women over age 35, blacks, Asians o Causes: estrogen stimulation o S/S: abnormal uterine bleeding, pain, symptoms on nearby structures, heavy bleeding, urinary symptoms due to bladder pressure o Causes problems with pregnancy, estrogen problems o Tx: myomectomy—removes fibroid tumor, used for younger women, hysterectomy used if bleeding worsens Nonsurgical—embolization of the artery that supplies the fibroids o Meds: BC pills, Lupigen—decreases bleeding and shrinks the fibroids Adenomyosis Endometrios o Presence of functioning endometrial tissue outside of the uterus o Ectopic tissue responds to hormonal changes o Risk factors: startist period early, cycle less than 27 days, bleeding lasts more than 7 days, heavy bleeding, 1 degree relatives with the disorder o Frequency and severity of symptoms do not correlate with extent or site of lesions o Theory: retrograde menstruation as cause, genetic predisposition o Implants can occur throughout the body, but usually on pelvic organs o Ectopic tissue proliferates, breaks down, and bleeds in conjunction with the normal menstrual cycle o S/S: infertility, abnormal vaginal bleeding, dysmenorrhea, constipation, diarrhea, dyspareunia o Chocolate cyst—the result of endometriosis; filled with old blood and can rupture o Tx: hormone replacement therapy—Depo Provera Cancer Cervical Cancer o 2nd most common cancer o Occurs more often in white women o Risk Factors: sex before age 16, multiple partners, HPV, STD, long term BC pills, exposure to DES, genetic, anal sex Vaginal Vulvar Endometrial Cancer and Uterine Sarcoma Ovarian Cancer o Causes more deaths than any other cancer of female reproductive tract o Diagnosed late, no diagnostic test for early detection. With family history, ultrasounds periodically may be done o White, older age, genetic, BRACA 1 & 2 gene Metastatic Ovarian Cancer o Usually not diagnosed until it reaches this point o Dx: abdominal and transvaginal ultrasound, CT scan, CA125 tumor marker 4 Ch. 49: Female Reproductive System AH2 Exam 5 o Tx: total hysterectomy, chemo, radiation Pap Smear Care o No sex 2448 hours before or after o Procedure is uncomfortable but should not be painful o No douching before bc that will skew results o Abnormal result can be bc of something the pt. did before the procedure Sexual Dysfunction Sexual anorexia or decreased libido Depression, drugs, alcohol common causes Anorgasmia: inability of woman to achieve or reach orgasm‐ chronic diseases Rapid orgasm: little interest after Dyspareunia: painful intercourse‐may be due to inadequate lubrication Other causative factors: Hx of sexual trauma, marital or relationship problems Infertility Inability to conceive after 1 year of unprotected sex Male: diminished quality and production of sperm Female: malfunctions of fallopian tubes, ovaries, or reproductive hormones Breast Disorders GalactorrheaL inappropriate lactation Fibrocystic breast disease Breast Cancer Breast Cancer risk (ACS) o Age 25: 1 in 19,608 o Age 80: 1 in 15 o Ever: 1 in 8 Clinical presentation: o Lump that is painless, nontender, and fixed, may be detected on SBE o Most common location is upper outer quadrant—48 % o nipple discharge, retracted nipple, pitting of skin, asymmetric breasts (grossly different) Risk Factors: increasing age, white, women, dense breast tissue, starting menstrual cycle before age 12 or menopause after age 55, long term HRT use, history or 25 alcoholic drinks/day, overweight Tx: aspiration needle biopsy to diagnose, excisional biopsy, mastectomy—teach exercises to use after sx to prevent lymphedema (mastectomy can be modified or radical, unilateral or bilateral) Mammogram—get it starting at age 40 unless genetic history then before age 40 5 Ch. 50: STIs & STDs AH2 Exam 5 Chapter 50: Sexually Transmitted Infections & Diseases Genital Herpes Genital Herpes is a sexually transmitted disease (STD) caused by the herpes simplex viruses type 1 (HSV1) or type 2 (HSV2). Herpes Simplex Virus I (HSV1) e.g. cold sore Herpes Simplex Virsus II (HSV2) e.g. genital herpes Pathophysiology Virus of the stratified squamous epithelium stimulating replication of the epithelium and infecting the neurons that innervate the area. They grow in neurons and can maintain disease potential without manifestations. Ascends through peripheral nerves to the dorsal root ganglia where it remains dormant There are over 100 types of HSV with over 30 infecting the genitourinary area. During dormancy, virus is impervious to treatment Incubation period ranges from 6 weeks 8 months HSVII is more common in women (1:4) versus men (1:8) Manifestations Herpetic Lesion Regional lymphadenopathy Headache Fever General malaise Dysuria Urinary retention Vaginal discharge Urethral discharge (men) Within 210 days post exposure to HSV, painful red papules appear in genital area. In men, the lesions generally occur on glans or shaft of penis In women, lesions commonly occur on the labia, vagina, and cervix. Anal or anal/oral sexual contact may result in legions in and around anus. Soon after, papules appear, they form small painful blisters filled with clear fluid containing virus particles Blisters break, shedding the highly infectious virus creating painful patches of ulcers that last 6 weeks longer. Touching these blisters and the rubbing or scratching in another place can spread infection to other parts of body (autoinoculation) Transmission Sexual activity or during childbirth from an infected women (HSV2) Associated with cold sores, may be transmitted to genital area by oral intercourse or self inoculation via poor hygiene practices (HSV1) Infection is more easily transmitted from men to women than from women to men. What to do if you think you have it: If lesion is present, visit primary care physician to run diagnostic tests such as: Direct (or virologic) tests detect viable virus, viral antigen, or viral nucleic acid. 1 Ch. 50: STIs & STDs AH2 Exam 5 Viral culture is currently the reference standard for diagnosing genital herpes. Culture requires collection of a sample from the sore and, once viral growth is seen, specific cell staining to differentiate between HSV1 and HSV2 You and your partner should get tested if one of you has an outbreak. Treatment No cure—antivirals prevent or shorten outbreaks during the pt of time the person takes them. Daily suppressive therapy (daily antivirals) can reduce the likelihood of transmission to partners. Typical meds: Acyclovir (Zovirax), Foscarnet (Foscavir), Valacyclovir (Valtrex), Famciclovir (Famvir) Keep lesions dry, wear loose cotton pants, help pt deal w/ dysuria, increase fluid intake, sitz baths Talk to pt. about low selfesteem How common is it? CDC estimates that, annually, 776,000 people in the US get new herpes infections. Genital herpes infection is common in the United States. Nationwide, 16.2% of persons aged 14 to 49 years have HSV2 infection. Gonorrhea Gonorrhea is also known as “GC” or “the Clap” or “the drip” Caused by Neisseria gonorrhoeae, a gram negative diplococcus The most common reportable communicable disease in the US One out of four adults get this disease it is very contagious Gonorrhea rates for African Americans are 8 x that of nonHispanic whites 1524 year old young women hold the highest number of this STD and men of this STD are around 2029 years old The South holds the largest number of Gonorrhea infections in the US (YEE HAW) Pathophysiology Gonorrhea is caused by a pyogenic (pus forming) bacteria. The bacteria causes inflammation and purulent exudate. Humans are the only host for the organism. It is transmitted by sexual contact and can be transmitted to infants during delivery The bacteria can enter through the genitourinary tract, eyes, oropharynx, anorectum, or the skin. The incubation period of the bacteria is 2 to 7 days after exposure. Initially, the bacteria targets the male urethra and the female cervix. Without prompt treatment, the disease will ultimately spread to other organs. In men: causes painful inflammation of the prostate, epididymis, and periurethral glands. Can lead to sterility. In women: can cause PID, endometritis, salpingitis, and pelvic peritonitis Manifestations Manifestations of anorectal gonorrhea (primarily in homosexual men): pruritus, mucopurulent rectal discharge, rectal bleeding and pain, and constipation. Manifestations of gonococcal pharyngitis: fever, sore throat, and enlarged lymph nodes. Men: o 20% remain asymptomatic until the disease is advanced o Dysuria o Serous, milky, or purulent discharge from the penis o Regional lymphadenopathy 2 Ch. 50: STIs & STDs AH2 Exam 5 Women: o 80% remain asymptomatic until the disease is advanced o Dysuria o Urinary frequency o Abnormal menses (increased flow or dysmenorrhea) o Increased vaginal discharge o Dyspareunia (painful intercourse) Complications Increased susceptibility to HIV Spread of infection to blood and joints Blindness Men: o Epididymitis o Prostatitis o Infertility o Dysuria Women: o PID can lead to internal abscesses o Chronic Pain o Ectopic pregnancy o Infertility o Lethal infections in newborn Care of a Patient Eradication of the organism and any coexisting disease Prevention of reinfection or transmission Take all medications as prescribed Abstain from sexual intercourse until infection is cured in both patient and partner Condom use to prevent future infection The only way to never get this disease is abstinence Diagnosis NAAT (nucleic acid amplification test) of specimens obtained from infected mucous membranes (cervix, urethra, rectum, or throat) Urine specimen Culture and sensitivity is performed for gonorrhea infection that is resistant to treatment Testing for other STI’s (especially chlamydia and syphilis) at the same time is recommended Medications Most patients with uncomplicated gonorrheal infections are treated with a single oral dose of an antibiotic such as: o Ceftriaxone o Cefixime o Ciprofloxacin o Ofloxacin o levofloxacin Because patients with gonorrhea frequently also are infected with C.trachomatis, concurrent treatment with azithromycin or doxycycline is recommended Strains of N.gonorrhoeae resistant to the quinolone antibiotics are increasingly prevalent Nursing Assessment 3 Ch. 50: STIs & STDs AH2 Exam 5 Nurses must consider the possibility of coexisting STIs such as syphilis and HIV. Ask: o Having difficulty or painful urination o Discharge from vagina or penis o Change in menses or painful intercourse (women) o Experiencing sore throat, fever, swollen or tender lymph nodes o Number of sexual partners o Participation in safe sex practices (condoms) Assess for: o Presence of penile, vaginal or anal discharge o Regional lymphadenopathy Nursing Diagnoses and Interventions Noncompliance o Onetime treatment with recommended antibiotic is highly effective in curing gonorrhea, however; noncompliance with doxycycline (antibiotic) may leave any coexisting chlamydial infection unresolved o Noncompliance with any of the following affect treatment: o Abstinence, followup appointments, use of condoms Interventions o Reinforce the need to take all medications as directed and keep followup appointments to be sure no reinfection has occurred o Discuss complications if gonorrhea is not cured o Discuss the importance of sexual abstinence until the infection is cured, referral of partners and condom use for prevention o Explain to women that condoms must be used during treatment, even if other methods of birth control are used Impaired Social Interaction o Any STI can make patients feel “dirty,” ashamed, guilty about their sexual behaviors, and unworthy to be with others Interventions o Provide privacy, confidentiality, and a safe, nonjudgmental environment for expression of concerns o Help the patient understand that gonorrhea is a consequence of sexual behavior, not a punishment, and that it can be avoided in the future Community Based Care Taking any and all prescribed medication Referring sexual partners for evaluation and treatment Abstaining from all sexual contact until the patient and partners are cured Using a condom to avoid transmitting or contracting infections in the future Genital Warts (HPV) HPV Pathology Genital warts are caused by the human papillomavirus (HPV). Transmitted by vaginal, anal, or oralgenital contact. HPV infects squamous epithelium. Low risk HPV subtypes are found in external genital warts. High risk subtypes are related to cervical dysplasia and anogenital cancers. 4 Ch. 50: STIs & STDs AH2 Exam 5 Smoking, immunosuppression, and altered hormone levels can affect the risk for cancer development that relates to HPV infection. 4 different types: Condoloma—cauliflower shaped, Keratotic—thick/hard, Papular—smooth with keratinized skin, Plaque—slightly raised Manifestations Some may be asymptomatic Others exhibit characteristic lesions that are painless, soft, moist, pink or fleshcolored Lesions can be present in the vulvovaginal area, perineum, penis, urethra, anus, groin, or thigh In women, growths may be on the vagina or cervix and only apparent during a pelvic exam Diagnosis Clinical appearance, Pap tests, HPV DNA test Treatment Remove warts Relive symptoms Teaching to reduce risk of recurrence and future transmission Meds: Gardisil vaccine—preventative. Topical agents—podophyllin, imiquimod Others: cryotherapy, electrocautery, laser vaporization, surgical excision, carbon dioxide laser surgery—burns off the warts Nursing Interventions Educate all women, especially adolescents and the mothers of young girls, about the HPV vaccine and immunization recommendations Educate clients with genital warts about prompt treatment and sexual abstinence until lesions have healed, or using a condom while lesions are present in order to decrease the risk of reinfection and further transmission of disease Discuss the increased risk of cervical cancer associated with HPV and the importance of yearly pap smears for all sexually active females Teach the importance of hand hygiene and its impact on the prevention of spreading HPV Teach the client with genital warts about treatment options and discuss the option of surgery or cryotherapy Encourage and listen to the client express their feelings and fears of surgery Have the doctor or surgeon explain the procedure, potential complications of the procedure, and ways to avoid the possible complications. Also note that the procedure is performed under local anesthesia, to inform the client that they will be awake during the procedure. Community Based Care Health teaching emphasizes the need for patient and infected partners to return for regular treatment until lesions have fully resolved, and to use condoms to prevent reinfection. Due to the increased risk of cervical cancer, the nurse should educate female partners the importance of annual Pap smears. Vaginal Infections The vagina can be infected by yeasts, bacteria, or protozoa. It can be sexually transmitted. Preventive measures: o Personal hygiene o Safer sex o Avoid douching, nylon underwear, or tight pants 5 Ch. 50: STIs & STDs AH2 Exam 5 Bacterial Vaginosis Most common cause of vaginal infections Vaginal discharge is thin, grayishwhite (milklike), and has a foul fishy odor. Treated with oral or intravaginal antibacterial agents (antibiotics) Candidiasis Yeast infection Vaginal discharge is odorless, thick, and cheesy Treated with oral or intravaginal antifungal agents Trichomoniasis Most common curable STI in young, sexually active women. Increases a woman’s risk of developing HIV if she is exposed and may increase the risk of transmitting HIV to her sex partner Vaginal discharge is frothy, greenyellow with a strong fishy odor Treated with a single oral dose of metronidazole (Flagyl) or tinidazole Diagnosis Cervical cultures to diagnose the causative organism Trichomonas is identified by microscopic exam of a specimen of vaginal discharge in saline Candida is identified by using 10% potassium hydroxide to identify spores and filaments Medications Sexual partner of a woman with trichomonas infection must also be treated to prevent reinfection Focus of Care Interdisciplinary care focuses on identifying and eliminating the infection and preventing reoccurrence. Nursing care focuses on: o Compliance: teaching the patient to comply with the treatment regimen. o Safe sex practices: to prevent future transmission of the infection. Nursing Diagnoses: Deficient Knowledge: Many women are unaware of what causes vaginal infections. o Explain the transmission of the infection. Most infections are transmitted easily during menstruation, by towels or other objects, and certain types of sexual activity. o Express the importance of completing the course of treatment. o Advise women that 8oz of yogurt containing live cultures may prevent recurrent vaginal infections. Acute Pain: The symptoms of vaginal infections can cause pain. o Suggest the use of cool compresses. o Recommend sitz baths to alleviate discomfort. o Wear cotton underwear. Chlamydia Most common bacterial STI in the United States. Found most frequently in adolescents and young adults. Transmission is thru vaginal sex. Caused by Chlamydia trachomatis. An intracellular bacterium with different immunotypes. Immunotypes of chlamydia are responsible for lymphogranuloma venereum and trachoma, the world’s leading cause of preventable blindness. Manifestations 6 Ch. 50: STIs & STDs AH2 Exam 5 Incubation period 13 weeks Dysuria Urinary frequency Vaginal discharge in women Urethral discharge in men May be asymptomatic but can still spread to partners Complications Ascension into upper reproductive tract Pelvic inflammatory disease Endometritis Salpingitis Infertility Ectopic pregnancy Epididymitis Prostatitis Sterility Diagnosis: Urine specimen or swab of the vagina, endocervix, urethra, or rectum used to diagnose C. trachomatis. Enzymelinked immunosorbent assay (ELISA), polymerase chain reaction (PCR), or nucleic acid amplification test (NAAT) may be done to check for antibodies to Chlamydia. Medications: Antibiotic Azithromycin (Zithromax) Doxycycline (Adoxa, ApoDoxy) Both partners need to be treated Focus of Care: Interdisciplinary care focuses on treating C. trachomatis with meds to eradicate the infection. Nursing care focuses on the: o Eradication of the infection o Prevention of future infections o Management of any chronic complications Nursing Diagnoses: for the pt with Chlamydia nursing diagnoses are the same as for any STI. o Ex. Deficient Knowledge, Impaired Social Interaction, Risk for Injury, Pain, and Sexual Dysfunction. CommunityBased Care—Health Teaching: o Complying with treatment regimen o Refer partners for examination and treatment o Use condoms to avoid reinfection o CDC recommends annual screening for young sexually active men and women. Syphilis Pathophysiology Spirochete Treponema pallidum; complex sexually transmitted disease that can affect any body tissue or organ that is vulnerable to invasion. After this disease enters a body system it usually spreads through the blood and lymphatic system. 7 Ch. 50: STIs & STDs AH2 Exam 5 Congenital syphilis can be transferred through the placental circulation from mother to fetus This STI is usually transferred through open lesions such as genital, oralgenital, or analgenital. Even though this organism is highly susceptible to heat and drying, it can survive for a decent length of time in fluids; therefore, syphilis can be transmitted by infected blood or other body fluid such as saliva. Manifestations Stage 1: Primary o Chancre (hard, syphilitic primary ulcers) appears on genitals, anus, mouth, breast, fingers, 3 to 4 weeks after infectious contact o A woman’s chancre may go unnoticed or may be internal o Regional lymphadenopathy Stage 2: Secondary o Skin rash: palms of hands or soles of feet o Mucous patches in oral cavity o Sore throat and flulike symptoms o Generalized lymphadenopathy o Condyloma lata (flat, broadbased papules) on labia, anus, or corner of mouth o Alopecia o Meningitis, headache or cranial neuropathies o Arthralgia, myalgia, bone and joint arthritis, and perostitis (tenderness and swelling of affected bone) o Glomerulonephritis and nephrotic syndromes o Hepatitis o Usually disappears in 26 weeks Stage 3: Tertiary o Can last 250 years, infect via blood in this stage o Benign Late Syphilis: rapid onset characterized by localized development of infiltrating tumors (gummas) in skin, bones, and liver o Insidious Onset Diffuse inflammatory response that involves the CNS and the cardiovascular system Neurosyphilis, seizures, hemiparesis, hemiplegia Personality changes, hyperactive reflexes, Argyll Robertson pupil, decreased memory, slurred speech, optic atrophy Aortic insufficiency, aortic aneurysm, stenosis of coronary arteries Diagnostic Testing Darkfield microscopy: This test uses a special microscope to examine a sample of fluid or tissue from an open sore (chancre) for the syphilis bacteria. This test is used mainly to diagnose syphilis in an early stage. Microhemagglutination assay (MHATP): The MHATP is used to confirm a syphilis infection after another method tests positive for the syphilis bacteria. Venereal disease research laboratory (VDRL) test: The VDRL test checks for an antibody that can be produced in people who have syphilis. This antibody is not produced as a reaction to the syphilis bacteria specifically, so this test is sometimes not accurate. The VDRL test may be done on a sample of blood or spinal fluid. The VDRL test is not very useful for detecting syphilis in very early or advanced stages. 8 Ch. 50: STIs & STDs AH2 Exam 5 Enzyme immunoassay (EIA) test: This is a newer blood test that checks for antibodies to the bacteria that cause syphilis. A positive EIA test should be confirmed with either the VDRL or RPR tests. Treatment Treatment for early stages consists of a single IM injection of penicillin (antibiotic). This will cure a person who has had syphilis for less than a year. Treatment for someone who has had syphilis for longer than a year requires additional doses of penicillin. Other antibiotics are available to treat syphilis for those who are allergic to penicillin such as tetracyclin or doxycycline. Treatment will kill the syphilis bacterium and prevent further damage, but it will not repair damage already done During treatment people must abstain from sexual contact with new partners until the syphilis sores are completely healed No home remedies or OTC drugs cure syphilis Prevention To prevent getting syphilis, you must avoid contact with infected tissue (a group of cells) and body fluids of an infected person. However, syphilis is usually transmitted by people who have no sores that can be seen or rashes and who do not know they are infected You can also prevent infection by: o Not Getting Semen Or Blood In Your Mouth o Avoiding Oral Sex If You Have Mouth Ulcers Or Bleeding Gums o Not brushing your teeth immediately before oral sex 9 Bladder Incontinence & Retention AH2 Exam 2 Bladder Incontinence & Retention Urinary Tract (Bladder) Tumor 90% of malignant tumors develop in the bladder; 8% in renal pelvis; only 2% in ureters or urethra Two major risk factors: presence of carcinogens in the urine and chronic inflammation or infection of bladder mucosa o *Cigarette smoking is the primary risk factor for bladder cancer o Other risk factors: male gender, age > 60, urban area living, occupational exposure to dyes or solvents, chronic phenacetin ingestion, chronic UTI or bladder stones Carcinoma in situ (CIS): occurs less frequently, a poorly differentiated flat tumor that invades directly and is associated with a poorer prognosis Clinical Manifestations o *Painless hematuria—most common presenting sign o Manifestations of a UTI—frequency, urgency, and dysuria o May cause colicky pain from obstruction o Typically, few outward signs are noted until obstructed urine flow causes flank pain or renal failure, resulting in late discovery of the tumor Bladder Tumor Staging Depth of TNM (Tumor, Node, Involvement Stage Metastasis) Stage Tumor Involvement Superficial Cis Ta Limited to the bladder mucosa I T1 Bladder mucosa and submucosal layers Invasive II T2 Invasion of superficial muscle of bladder wall T3a Deep muscle invasion III T 3b Involvement of perivesicular fat IV T34 + Regional pelvic lymph node involvement T M Metastasis to distant lymph nodes or organs 34 1 Diagnostic Tests UA: evaluate for hematuria Urine cytology: microscopic examination of cells in the urine Ultrasound of the bladder: detects bladder tumors IVP: may reveal a rigid deformity of the bladder wall, obstruction of urine flow at the point of the tumor, or bladder filling or emptying defects Cystoscopy: allow direct visualization, assessment, and biopsy of lesions CT scan or MRI: evaluate tumor invasion or metastasis Meds for Urinary Tract Tumor Immunologic or chemotherapeutic agents administered by intravesical instillation Bacille Calmette Guerin (BCG): suspension of mycobacterium bovis used to treat CIS and recurrent bladder tumors o Instillation into bladder causes an inflammatory reaction that reduces/eliminates superficial tumors May use other chemotherapeutic agents 1 Bladder Incontinence & Retention AH2 Exam 2 Radiation therapy to reduce tumor size or palliative tx Surgery Cystectomy: removal of the bladder Urinary diversion: created to provide for urine collection o Ileal conduit: ileum is formed into a pouch with the open end brought to the surface to form a stoma and ureters are inserted into pouch Nsg care: most common urinary diversion, continuous urine drainage, skin care bc of constant contact with urine o Cutaneous urostomy: each ureter is brought to the surface of the abdomen to form a stoma Nsg care: requires dual appliances, skin care o Continent urinary reservoir (aka Koch pouch): portion of stomach, colon, or small intestine is used to form a reservoir to which the ureters are attached; nipple valves are formed to prevent reflux Nsg care: drainage collection device not necessary, pt. must be able to manage selfcatheterization, drainage is always a little cloudy due to the mucous that helps move the urine along the tract Stoma Care: normal stoma—bright red and appears moist; abnormal/need to report to HCP—dark purple, black or pale, p. 803804 Nursing Care Promptly report urine output of less than 30 mL per hour, which may indicate low vascular volume or renal insufficiency. Prompt intervention is vital to restore cardiac output and prevent acute renal failure. Use aseptic techniques and strictly follow guidelines for irrigating catheters. Catheters placed in the kidney pelvis are irrigated using gentle pressure and small amounts of fluid (10 to 15 mL) to avoid damaging renal tissues. Monitor urine output closely for first 24 hours after stents or ureteral catheters are removed. Edema or stricture of ureters may impede output, leading to hydronephrosis and kidney damage Urinary Incontinence **Not normal consequence of aging 30% older women experience it 50% in long‐term care, foster care, home‐bound Etiology and Pathophysiology Many types of incontinence Reversible or irreversible o Congenital disorders: epispadias, meningomyelocele o Acquired disorders: CNS or spinal cord trauma, stroke, chronic neurological disorders (MS), and Parkinson’s o Chronic disorder o Reversible: acute confusion, medications, BPH, vaginal and urethral atrophy, UTI, fecal impaction Risk Factors Women more than men* Smokers Older adults housebound Living in nursing homes 2 Bladder Incontinence & Retention AH2 Exam 2 Medication Other factors Types of Urinary Incontinence Type Description Pathophysiology Contributing Factors Stress Increased intraabdominal Relaxation of pelvic Multiple pregnancies pressure (sneezing, coughing, musculature and weakness or Decreased estrogen levels lifting) urethradecreased urethral Short urethra resistance Abd wall weakness Prostate surgery Tumor, ascites, obesity Urge A strong urge to void Overactive detrusor Neurologic disorders muscleincreased pressure w/in Detrusor muscle overactivity bladder and inability to inhibit voiding Overflow Inability to empty Outlet obstructionoverfilling Spinal cord injuries below S2 bladderoverdistension and of bladder and increased Diabetic neuropathy freq. loss of small amounts of pressure Prostatic hypertrophy urine Fecal impaction Drugs (anticholinergic effect) Functional Resulting from physical, Ability to respond to the need Confusion, dementia environmental, or to urinate is impaired Physical disabilities psychosocial causes Impaired mobility Therapy or sedation Depression Regression Mixed Combined form of stress, urge, and overflow incontinence Total The loss of all voluntary urinary control Clinical Manifestations Inability to avoid urinating Inability to urinate Increased rate of urinations Leakage Uncontrollable wetting urge incontinence, or overflow (increases infection risk) Frequent bladder infections Developmental considerations Diagnostic Tests Urinalysis and urine culture: assess for UTI Postvoiding residual: determines how the bladder is emptying o < 50 mL is expected; >100 mL indicates need for further testing Cystometrography: evaluation of neuromuscular function of bladder (detrusor muscle fx) o Urge to void occurs at 150 – 450mL o Bladder feels full at 300 – 500mL 3 Bladder Incontinence & Retention AH2 Exam 2 Uroflowmetry: noninvasive test to evaluate voiding pattern IVP: evaluates structure and function of urinary tract Cystoscopy or ultrasound: identify structural disorders, such as enlarged prostate or a tumor Medications, p. 812 Drugs that contract smooth muscles of bladder neck: phenylpropanolamine (often seen in OTC decongestants and diet aids) tx mild stress incontinence Drugs that inhibit uptake of NE and serotonin (Cymbalta/Duloxetine) drugs of choice for treating stress incontinence Incontinence with postmenopausal atrophic vaginitis topical estrogen therapy (cream) Urge incontinence: antihistamines and/or anticholinergic o Drugs to inhibit detrusor muscle contractions o Increase bladder capacity: oxybutynin (Ditropan), tolterodine (Detrol) o Antihistamines will tighten sphincter Stress Incontinence: cholinergic meds to increase bladder pressure Surgery, p. 813 Cystocele stress incontinence Urethrocele stress incontinence Enlarged prostate removal of the prostate to tx overflow incontinence Suspension of bladder neck: technique that brings the angle between the bladder and the urethra closer to normal; effective in tx stress incontinence associated with urethrocele Preoperative care: o Avoid straining and Valsalva maneuver postoperatively o Increasing fluid and fiber intake, using a stool softener to prevent postop constipation Postoperative care: o Monitor urine OP, quantity, color, clarity (expect it to be pink tinged initially) o Maintain stability and patency of suprapubic and/or urethral catheters o Monitor for difficulty voiding after catheter removal o Teach proper care of the catheter to the pt. and family members Complimentary Therapies Biofeedback Relaxation techniques Health promotion Psychosocial effects Client Teaching Maintain generous fluid intake; do not limit intake to any less than 2 L/day, but do reduce fluid intake in the evening Instruct pt to keep a voiding diary recording the time & amount of intake & output. Wear comfortable clothing that is easy to remove Maintain good hygiene Reduce consumption of caffeinated fluids, citrus juices, aspartame (artificial sweeteners), alcohol Behavioral techniques o Regimen toileting: q2h when awake, go try to empty bladder o Bladder retraining: Crede’s method—applying pressure to the suprapubic region with the fingers of one or both hands and bending forward to promote bladder emptying for the pt. with a spastic or flaccid bladder Regular primary care examinations 4 Bladder Incontinence & Retention AH2 Exam 2 Discuss benefits and risks of HRT, PT, and surgery Report changes in urine, symptoms to primary care provider Pelvic Floor Muscle (Kegel) Exercises, p. 804 o Identify pelvic muscles o Perform exercises by tightening muscles Hold for 10 seconds Relax for 10–15 seconds 10 repetitions o Keep abdominal muscles, breathing relaxed o Initially, perform 2x/day work up to 4x/day Assess physical and mental status, limitations, and need for assistance with toileting. Encourage the use of assistive devices including grab bars, elevated toilet seat, bedside commode, and night lights. Plan toileting schedule based on normal elimination patterns. Position for ease of voiding and provide privacy. Urinary Retention Incomplete emptying of the bladderoverdistension of the bladder, poor detrusor muscle contractility, and inability to urinate Cause Characteristics Obstruction BPH (common cause) Fecal impaction Calculi Functional Inflammation of the bladder Problem Scarring of structure from repeated UTIs Surgery that disrupts detrusor muscle function (esp. abdominal surgery) Accident or infections: brain, spinal cord Medictions Anticholinergics Antipsychotic medications Antianxiety medications Sedatives Antidepressants Hypnotics Antiparkinsonians Antihistamines Conscious Waiting to empty the bladder can lead to: overfilling and loss of detrusor muscle tone Inhibition Clinical Manifestations Overflow voiding or incontinence Discomfort due to inability to empty bladder Difficulty starting urination Firm, distended bladder; may be displaced from the midline Percussion: dull tone fluid/urine in bladder (full) Complications Hydroureter: distention of the ureter with urine Hydronephrosis Acute renal failure: a sudden decrease in or total lack of kidney function; it can be reversed with prompt treatment. 5 Bladder Incontinence & Retention AH2 Exam 2 Medications Promote contraction of detrusor muscle Promote emptying of bladder Surgeries and Procedures Indwelling urinary catheter Intermittent straight catheterization Remove or repair obstruction, calculi Resection of prostate Nursing Process Assessment Health history o Physical examination, physical status, limitations, mental status, cognition, inspection, palpation, percussion, hydration status Nursing Diagnoses Functional Urinary Incontinence, Reflex Urinary Incontinence, Stress Urinary Incontinence, Urge Urinary Incontinence, Total Urinary Incontinence, Overflow Urinary Incontinence Urinary Retention Problems of urinary elimination etiology for other problems o Urinary retention, invasive procedures infection o Incontinence low self‐esteem, social isolation, impaired skin integrity o Self‐care deficits o Disturbed body image o Deficient knowledge o Caregiver role strain Planning Maintain or restore normal pattern Regain normal urine output Prevent associated risks Perform activities independently Contain urine with appropriate device Home Care o Facilitating urinary elimination self‐care o Promoting urinary elimination o Asepsis o Medications o Dietary alterations o Referrals o Community agencies o Additional resources: National Council of Independent Living, National Association for Continence, Simon Foundation for Continence Implementation: combination of strategies Education Bladder training Habit training Prompted voiding Pelvic muscle exercises 6 Bladder Incontinence & Retention AH2 Exam 2 Maintaining skin integrity o Wash perineal area o Provide clean, dry clothing and bed linen o Apply barrier ointments, creams o Pad bed as necessary Maintaining normal voiding habits Promoting Urination o Nursing Measures Place the pt in normal voiding positioning, provide privacy Utilize measures such as running water, placing the pt’s hands in warm water, pouring warm water on the perineum, or taking a warm Perform urinary catheterization as prescribed; limit urine draining to 500mL increments to prevent vasovagal response Notify HCP with the amount of urine removed from cath and characteristics of urine OP o Acute Retention Coudé‐tipped catheter: Red Robin, firmer end, for prostate enlarg
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