Digiulio M., Keogh J. Medical-Surgical Nursing Demystified
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tract of the woman is at issue. Primary infertility is when a woman has never had
a pregnancy; secondary is when it occurs in a woman who has had one or more
pregnancies.
WHAT WENT WRONG?
At fault may be decreased secretion of hormones from the anterior pituitary, failure
to ovulate, endometriosis, or past infections causing blockage of the reproductive
tract. Structural problems (blocked fallopian tubes, or anovulation), poor sperm
motility and/or count, or multifactorial problems can cause infertility. Prior expo-
sure to radiation, medications, exercise frequency, and menstrual cycle and length
need to be evaluated.
PROGNOSIS
Infertility affects about 15 percent or more of couples.
HALLMARK SIGNS AND SYMPTOMS
•
Inability to achieve conception
INTERPRETING TEST RESULTS
•
Semen analysis.
•
Menstrual diary.
•
Sonogram to view endometrial anatomy.
•
Endometrial biopsy to check on hormone status and to determine if
the lining is able to support a fertilized ovum, and if leiomyomas are
present.
•
Labwork: hormone levels—progesterone, LH, FSH, TSH to check on nor-
mal uterine, ovarian, pituitary, and thyroid function.
•
Hysterosalpingogram to view uterus, fallopian tubes.
•
Postcoital test—cervix is checked for patency and whether the mucous is
thin enough for sperm to penetrate.
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TREATMENTS
•
Treatments depend on the cause of the infertility.
•
For abnormal sperm findings:
•
Urology referral.
•
Check medications—calcium channel blockers can impair sperm function.
•
Artificial insemination.
•
For anovulation:
•
LH/FSH to stimulate ovulation.
•
Bromocriptine for hypothalamic dysfunction.
•
Clomiphene to stimulate ovulation.
•
For structural aberrations:
•
Surgery to repair tube.
•
Myomectomy to remove leiomyomas.
•
Surgery to lyse adhesions.
•
In vitro fertilization.
NURSING DIAGNOSES
•
Body image disturbance
•
Defensive coping
•
Risk for parenting
NURSING INTERVENTIONS
•
Explain to the patient:
•
Suggest support groups.
•
Encourage questions.
•
Discuss tests.
Menopause
Menopause is defined as 12 months without a menses. Few follicles are left to
mature, levels of hormones decline, ovulation no longer occurs, and the uterine
lining no longer needs to thicken in preparation for a fertilized egg.
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WHAT WENT WRONG?
Natural progression of life
PROGNOSIS
The average age of menopause in the United States is 51. About 50 percent of
American women experience some symptoms of menopause.
HALLMARK SIGNS AND SYMPTOMS
•
Lack of menstrual cycle
•
Breasts, vagina, and uterus shrink in response to decreased estrogen and
progesterone
•
Vasomotor flushing due to estrogen levels falling
•
Moodiness due to changing hormone levels
•
Cardiovascular risks increase due to less estrogen
•
Osteoporosis is a risk factor due to less estrogen
•
Vaginal mucous dryness from less hormones
INTERPRETING TEST RESULTS
•
Increase in FSH during menopause.
•
Decrease in LH during menopause.
•
Estrogen levels decline.
TREATMENTS
Some women elect to begin hormone replacement therapy (HRT) (in women with
a uterus) or estrogen replacement therapy (ERT) (in women without a uterus), to
ameliorate the vasomotor flushing and menopausal signs and symptoms, and to de-
crease the risk of coronary artery disease.
NURSING DIAGNOSES
•
Effective management of individual therapeutic regimen
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•
Decisional conflict
•
Personal identity disturbance
NURSING INTERVENTIONS
•
Explain to the patient:
•
Bodily changes.
•
Effects of HRT and ERT.
Ovarian Cancer
Ovarian cancer is the deadliest gynecological cancer because it is usually ad-
vanced before it is detected. There is no proven screening test for ovarian
cancer. There are no definitive early signs. Some women experience vague abdom-
inal discomfort and bloating.
WHAT WENT WRONG?
A woman who has never had a child or who has had only one or two children, is
at higher risk for ovarian cancer. Women with a history of breast cancer, colon
cancer, or a family history of these are at a higher risk of ovarian cancer. There is
an association between endometriosis and ovarian cancer.
PROGNOSIS
Unfortunately, prognosis for ovarian cancer is poor. Over 75 percent of women
are diagnosed at an advanced stage. The prognosis is more grim if the CA-125
level is elevated, and if the disease has spread. The higher the staging, the worse
the prognosis. Of stage IV patients, 5 percent survive five years.
HALLMARK SIGNS AND SYMPTOMS
•
Bloating from the enlarging tumor
•
Pelvic mass
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•
Dyspnea due to pressure from the diaphragm from an enlarging tumor
•
Ascites—abnormal abdominal fluid
INTERPRETING TEST RESULTS
•
An elevated CA-125 indicates a tumor may be malignant.
•
Transvaginal ultrasound for detection of disease.
TREATMENTS
•
Treatment depends on the staging at diagnosis.
•
Surgical staging is necessary.
•
Complete abdominal hysterectomy, with bilateral salpingo-oophorectomy,
omentectomy, and node dissection.
•
Complete removal of all visible tumor and metastasis-debulking.
•
Chemotherapy:
•
cisplatin
•
carboplatin
•
paclitaxel
•
Radiation.
NURSING DIAGNOSES
•
Ineffective breathing pattern
•
Hopelessness
•
Anxiety
NURSING INTERVENTIONS
•
Monitor CBC to check anemia.
•
Check vaginal bleeding.
•
Check incision site.
•
Abdominal assessment—check for bowel sounds, distention.
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•
Check vital signs, temperature.
•
Administer pain medication.
•
Emotional reassurance.
•
Explain to the patient:
•
Benefit of early ambulation.
•
Use of pain medication.
•
Treatments promoted by the oncologist.
Ovarian Masses, Benign
The most common ovarian cysts are follicular.
WHAT WENT WRONG?
The egg is enclosed in a follicle as it waits to be expelled monthly from the ovary.
When the follicle does not open to allow the egg out or the follicle is not reab-
sorbed, a benign cyst, a fluid-filled sac, may result.
PROGNOSIS
Most cysts resolve in several months. However, a small percentage of patients
experience discomfort or pain when the cyst does not resolve.
HALLMARK SIGNS AND SYMPTOMS
•
Asymptomatic
•
Changes in menstruation
•
Unilateral pelvic pain (usually one ovary is involved)
•
Sharp pelvic pain, which indicates rupture
INTERPRETING TEST RESULTS
•
Pregnancy test.
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•
Pelvic exam.
•
Ultrasound.
TREATMENTS
•
Watchful waiting since most cysts resolve.
•
Oral contraceptives.
•
Surgery to remove the cyst.
NURSING DIAGNOSES
•
Pain, discomfort
•
Anxiety
NURSING INTERVENTIONS
•
Reassure her that a large majority of cysts resolve.
•
Explain to the patient:
•
Cause of her pain.
•
The menstrual cycle, pain may be worse during ovulation.
•
Medication use.
Pelvic Inflammatory Disease
(PID)
PID is a variety of inflammation and infection of the upper genital tract, which
includes the uterus, fallopian tubes, ovaries and other structures. It includes endo-
metritis, salpingitis, oophoritis, tubo-ovarian abscess, and pelvic peritonitis.
WHAT WENT WRONG?
Bacteria from the cervix and vagina migrate to the upper genital tract. Usual organ-
isms include Chlamydia trachomatis, Neisseria gonorrhoeae, Escherichia coli, and
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Bacteroides. Most infections are due to a mix of bacteria. PID occurs most often in
sexually active women and is more common in adolescents. PID is more common
with multiple sexual partners, a young age, unprotected sex, and a history of sexu-
ally transmitted disease.
PROGNOSIS
About one in ten sexually active women will experience PID in her lifetime and
25 percent of those will experience a major complication such as infertility, ectopic
pregnancy, abscess, or chronic pain.
HALLMARK SIGNS AND SYMPTOMS
•
Abdominal tenderness
•
Adnexal tenderness (ovaries and fallopian tubes)
•
Cervical motion tenderness (pain on movement of the cervix) due to an
infection
•
Fever
•
Vaginal discharge
•
Dyspareunia (pain during intercourse)
•
Elevated white blood cell count
INTERPRETING TEST RESULTS
•
CBC will show an elevated WBC
•
Pregnancy test—beta hCG
•
Chlamydia test
•
Gonorrhea test
•
Venereal Disease Research Laboratory (VDRL) test for syphilis
•
Rapid Plasma Reagin (RPR) test for syphilis
•
Fluorescent Treponema Antibody (FTA–ABS) test used to confirm syphilis
•
Chandelier sign—a great amount of pain is elicited when the cervix is
touched (the woman will jump to the chandelier)
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TREATMENTS
•
Most patients are able to be managed in an outpatient setting with antibiotics:
•
ofloxacin and metronidazole
•
ceftriaxone and doxycycline
•
azithromycin and metronidazole
•
Those who are pregnant, who present with an abscess or peritonitis, or with
GI symptoms require inpatient treatment.
•
cefotetan and doxycycline
•
clindamycin and gentamycin
•
azithromycin and metronidazole
•
Sexual partners must also be treated.
NURSING DIAGNOSES
•
Pain, discomfort
•
Sexual dysfunction
•
Risk of infection
NURSING INTERVENTIONS
•
Teach patient about:
•
Spread of the disease.
•
Practicing safe sex.
•
Medication use and side effects.
•
Necessity of treating all partners.
Trophoblastic Disease
Trophoblastic neoplasias are abnormal cells growing from a shell that forms
between the embryo and the endometrium. The four disease entities are called
hydatidiform mole (partial or complete), invasive mole, choriocarcinoma, and pla-
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cental site trophoblastic tumor. A complete mole is formed when an egg that has no
DNA is fertilized by a sperm. A partial mole has DNA from both parents and usu-
ally fetal parts. An invasive mole is a hydatidiform mole in the endometrium.
Choriocarcinomas are tumors composed of trophoblasts with bleeding. Placental
site trophoblastic tumors are trophoblasts which intrude the myometrium. All are
suggestive of malignancy and require a full metastatic work-up, including CT scan
of brain, kidneys, liver, and lung.
WHAT WENT WRONG?
There is thought to be a problem with the genetic material of the zygotes. The
chances are increased with an older mother, prior molar pregnancy, and a history
of miscarriage.
PROGNOSIS
Prognosis is the best for a woman diagnosed with a hydatidiform mole. Approx-
imately 20 percent of complete mole pregnancies result in further trophoblastic
disease. The remaining three diagnoses may point to malignancy. Most non-
metastatic malignancies have a good remission rate after treatment.
HALLMARK SIGNS AND SYMPTOMS
•
Usual pregnancy signs during the first trimester
•
Vaginal passing of a grapelike cluster of vesicles
•
Vaginal bleeding
•
Abnormally elevted hCG
•
Abnormally large uterus
•
Absence of fetal heart tones
•
Elevated blood pressure
INTERPRETING TEST RESULTS
•
Pelvic examination.
•
hCG higher than expected serum levels in blood pregnancy test.
•
Ultrasound.