0133427269 Module19 Sexuality LectureOutline

Module 19 Sexuality The Concept of Sexuality Individually expressed, highly personal phenomenon ( meaning evolves from life experiences Development and sexuality Development of sexuality begins with conception ( continues throughout life span See LIFESPAN CONSIDERATIONS Sexual Development Throughout the Life Span, p. 1341 Birth to 12 years Ability to experience sexual response present before birth Males have erections before birth Babies find genitals ( pleasurable sensation Around age 910 ( first physical changes of puberty begin Breast buds in girls Growth of pubic hair Education about menstruation, related self-care Adolescence Early adolescence ( primary and secondary sex characteristics continue to develop Testes, scrotum increase in size, skin gets darker, pubic hair grows, axillary sweating begins Vaginal secretions change, pelvis and hips broaden, breast tissue develops, pubic hair grows, axillary sweating begins Menstruation irregular initially ( teach about subtle signs of impending menstruation, feminine hygiene products Dysmenorrhea prevalent among adolescent females Uterine contractions ( ischemia ( pain Treated with bed rest, analgesics, heat to abdomen, abdominal muscle strengthening exercises, biofeedback, nonsteroidal anti-inflammatory drugs (NSAIDs) Sexual experimentation occurring earlier than previous decades Sexually transmitted infections (STIs) most common bacterial infections among adolescents Adolescent often uneasy about discussing sexual behavior with parents Nurse ( provides factual, nonjudgmental information Young and middle adulthood Begin to form intimate relationships with long-term implications Young adult men, women concerned about normal sexual response for self, partners Middle adulthood ( men and women experience decreased hormone production ( climacteric Often affects sexual self-concept, body image, sexual identity Older adulthood Interest in sexual activity not lost as people age Men ( more time needed to achieve erection, ejaculation Women ( remain capable of multiple orgasm, may experience increase in sexual desire after menopause Many products available to assist older adults ( enhance sexual experiences May define sexuality more broadly ( include touching, hugging, romantic gestures, and so on Continue to need intimacy ( chosen emotional interconnectedness Age-related changes in sexual response ( arousal takes longer ( foreplay even more important Chronic pain, osteoarthritis ( may have deleterious effects on sexual activity in older adults Arthritis in hip joint Cardiovascular disease ( safety of sex ( climb two flights of stairs, walk at rate of 2 miles per hour without chest pain Dyspareunia ( may be related to decreased vaginal lubrication, lack of elevation of labia during sexual arousal Diabetes mellitus ( negative effects on sexual expression of both men and women Discussing sexuality with older adults PLISSIT model P( permission LI ( limited information SS ( specific suggestions IT ( intensive therapy Sexual health World Health Organization (WHO) defined sexual health ( integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love Components of sexual health Sexual self-concept ( determines with whom, gender, and kinds of people one is attracted to, when, where, how one expresses sexuality Body image ( constantly changing Media ( physical attractiveness, size of breasts, penis Body image can suffer when person unable to meet expectations Gender identity ( ones self-image as female or male Includes social, cultural norms Gender-role behavior ( outward expression of persons sense of maleness, femaleness as well as expression of what is perceived as gender-appropriate behavior Physical structure Family values Cultural values Freedoms and responsibilities Engage in activities that are freely chosen Ethically motivated to exercise behavioral, emotional, economic, and social responsibility for themselves Varieties of sexualities Sexual orientation Heterosexualbisexualhomosexual continuum Origins of sexual orientation not well understood Biologic/genetic theory Early learning/cognitive theory Estimate 510 men, 24 women ( homosexual orientation Gender identity Biologically, gradations run from female to male Intersex ( 1 in 2,000 babies born with intersex condition Contradictions among chromosomal gender, gonadal gender, internal organs, external genital appearance Transsexuals ( gender dysphoria, gender identity disorder Sexual anatomy not consistent with gender identity Male-to-female and female-to-male transsexuals Most report feelings from early childhood Often hide situation May live part or full time as members of other sex ( cross-dressing Sexual orientation may be hetero,- homo-, or bisexual Cross-dressing ( typically males who cross-dress to express feminine side of personality Conscious choice, may occur at home or public settings Erotic preferences Sexual fantasies, single-partner sex most common sexual outlets Masturbation ( self-stimulation of ones genitals for sexual pleasure Oral-genital sex ( cunnilingusfemale genitals, fellatiomale genitals Sixty-ninesimultaneous oral-genital stimulation by two people Anal stimulation Genital intercourse Variety of positions Man moves penis back and forth along vaginal walls Anal intercourse Commonly practiced by gay men, heterosexual couples Current practice ( condom use to prevent transmission of disease Anorectal tissue not self-lubricating ( lubricant Other varieties of sexuality Sexual response cycle Desire phase ( starts in brain with erotic stimuli Excitement phase Vasocongestion Myotonia Orgasmic phase ( involuntary climax of sexual tension with physiological and psychological release Male orgasm ( 1030 seconds ( ejaculation Female ( 1050 seconds Resolution phase ( period of return to unaroused state 1015 minutes after orgasm, longer if no orgasm See Table 191 PHYSIOLOGICAL CHANGES ASSOCIATED WITH THE SEXUAL RESPONSE CYCLE, p. 1347 Alterations in sexual function See CONCEPTS RELATED TO SEXUALITY, p. 1348 Ability to engage in sexual behavior ( important to most Many experience transient problems Past and current factors Sociocultural factors ( restrictive upbringing, inadequate sex education Psychological factors ( negative feelings History of sexual abuse Fears Depression Cognitive factors ( internalization of negative expectations and beliefs May be symptomatic of relationship problems Lack of intimacy, feeling like sex object inhibit feeling of communion, connection Health factors ( disease processes, surgery Relationship factors ( being in conflict with partner Lack of intimacy Feeling like a sex object Failure to communicate Alterations and manifestations Sexual desire disorders Sexual desire varies from day to day Hypoactive sexual desire disorder Disparity of sexual needs Sexual aversion disorder Sexual arousal disorders Female sexual arousal disorder ( lack of vaginal lubrication causes discomfort, pain during sexual intercourse Male erectile disorder ( diagnosis made when man has erection problems 25 or more of sexual interactions Orgasmic disorders Female orgasmic disorder (frigid) ( sexual response stops before orgasm occurs Preorgasmic ( woman who has never experienced an orgasm Male orgasmic disorder ( maintain erection for long periods, extreme difficulty ejaculating ( retarded ejaculation Rapid ejaculation ( one of most common Sexual pain disorders Both men and women can experience dyspareunia Pelvic disorders Infection or inflammation Vaginismus ( involuntary spasm of outer third of vaginal muscles, making penetration of vagina painful, sometimes impossible Vulvodynia ( constant, unremitting burning localized to vulva Vestibulitis ( severe pain only on touch, attempted vaginal entry Problems with satisfaction Commonly related to emotional tone of relationships May be situational Genitally focused ( neglecting rest of body May be related to relationship difficulties Lack of intimacy, feeling of connectedness Clients at risk for altered sexual patterns include those with Altered body structure Physical, psychosocial, emotional or sexual abuse, sexual assault Disfiguring conditions Specific medication therapy Temporary or long-term impaired physical ability to perform grooming and maintain sexual attractiveness Value conflicts between personal beliefs and religious doctrine Loss of partner Lack of knowledge, misinformation Prevalence More prevalent in women than men Hypoactive sexual disorder found in 1 38 of men and 31 49 of women Most prevalent male sexual dysfunction is erectile dysfunction ( about 30 million men Age-related 52 of men ages 40 70 report ED Genetic considerations Genetic influence on female sexual functioning See ALTERATIONS AND THERAPIES Sexuality, p. 1352 Case Study Part 1 ( The Jarvis family lives in a comfortable home in the suburb of a large city, p. 1352 Prevention Sexual relationships depend on health Choosing a healthy lifestyle will help prevent sexual dysfunction Screen tests include Regular physical checkups Screening for cholesterol and hypertension Screenings for STIs and HIV For women Pap tests Clinical breast exams and mammography For men Screening for prostate cancer with DRE after age 50 Screening for PSA for men at high risk Vaccines Gardasil ( protection from human papilloma virus, cervical cancer, genital warts, and cancer of the anus, vagina, and vulva Recommended for preteen boys and girls Teen boys and girls who were not previously vaccinated Women up to age 26 Men up to age 21 Cervarix ( protection from human papilloma virus and cervical cancer Assessment Nursing assessment Assessing men See ASSESSMENT INTERVIEW Male Sexuality, p. 1353 Begin with more general questions and progress to specific issues Assessing women See ASSESSMENT INTERVIEW Female Sexuality, p. 1354 Ask questions in a way that that allows client to describe behaviors and manifestation Assessing adolescents Guided by consideration of the teens cognitive and social development Use a nonjudgmental attitude and show genuine interest in the teen Teen should know that everything discussed is confidential Physical exams are similar to those for adults Physical assessment See MALE REPRODUCTIVE SYSTEM ASSESSMENT, p. 1356 See FEMALE REPRODUCTIVE SYSTEM ASSESSMENT, p. 1358 Lifespan and cultural considerations Family ( earliest and most enduring social relationship Children observe parents, model selves after these adults Common sexual messages children get from families Sex is dirty Premarital sex is sinful Good girls dont do it Masturbation is disgusting Men should be sexual experts Sex is mainly for procreating Bodies, including genitals, are beautiful Sex should be fun for both men and women Sexual thoughts and feelings are natural Masturbation is common, pleasurable activity There is great variety in sexual behavior Culture ( regulates sexuality Cultures differ ( which body parts found to be erotic Body weight Nudity Female circumcision ( female genital mutilation (FGM), female ritual cutting Cultural beliefs behind practice Long-term medical complications FGM illegal in several African and European countries, Canada, U.S. Male circumcision controversial Potential medical benefits however, insufficient data to recommend routine neonatal circumcision Religion Provides guidelines for sexual behavior, acceptable circumstances for behavior, as well as prohibited sexual behavior, consequences of breaking rules Many religious values conflict with more flexible societal values of past few decades Personal expectations and ethics Ethic integral to religion but can be viewed separately May be viewed as bizarre, perverted to one and natural and right to another Diagnostic tests Culture and sensitivity to determine causative agent of STI or other infections Serum hormone levels Urinalysis Papanicolaou smear (Pap smear) Colposcopy Biopsy CBC with differential Case Study Part 2 ( Ralph Jarvis, age 45, has not been himself for about a month , p. 1363 Interventions and therapies Independent Teaching client to perform breast or testicular self-examination Teaching related to prevention of STIs or prevention of transmission of STIs Provide sexual health teaching Counseling for altered sexual function Collaborative Surgery Surgical treatment of erectile dysfunction Pharmacologic therapy Medications to help clients maintain sexual health and ability Oral contraceptives Hormone replacement therapy Infertility medications See MEDICATIONS Sexuality and Reproduction, p. 1364 Dealing with inappropriate sexual behavior Clients may act out sexually by doing the following Exposing themselves Asking nurse to provide intimate physical care when they are capable of doing this themselves Touching or grabbing the nurses genitals or buttocks Making blatant sexual statements to the nurse Offering the nurse sex Whistling and/or making comments about nurses attractiveness or desirability Making sexual comments to another client in same room, visitors about the sexy nurse or what they would like to do sexually with the nurse Following are some possible reasons for this inappropriate behavior Fear or anxiety over future ability to function sexually Unmet needs for intimacy and sexual closeness because of hospitalization Misinterpretation of the nurses behavior as sexual or provocative Need for reassurance that they are still sexual beings and still sexually attractive Need for attention Confusion neurological impairment or trauma Need to control Need for power Belief that flirtatious behavior is expected because of media portrayals of nurses as sexy, available, experienced See Box 192 NURSING STRATEGIES FOR INAPPROPRIATE SEXUAL BEHAVIOR, p. 1365 Review The Concept of Sexuality Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Part 3 ( Eileen Jarvis, 65, has lived with her son Ralph and his wife Betty for the past 2 years , p. 1366 Exemplar 19.1 Erectile Dysfunction Overview Erectile dysfunction (ED) ( inability of male to attain, maintain erection sufficient to permit satisfactory sexual intercourse May or may not be associated with loss of libido Incidence increases with age Pathophysiology and etiology Normal physiological erection is a neurovascular even that requires Functional autonomic and somatic nerves Smooth and striated muscles in the penile shaft and pelvic floor Adequate arterial blood flow Etiology Psychological causes Physical causes Vascular Neurogenic Hormonal Iatrogenic See Table 193 CAUSES OF ERECTILE DYSFUNCTION, p. 1367 Risk factors Advancing age Diseases ( heart disease, diabetes Trauma Prescription, illicit drugs Alcohol Clinical manifestations Either complete inability to attain or inability to sustain and erection Chronic, intermittent, episodic Age-related changes ( takes longer to become sexually aroused, longer to complete intercourse, longer before sexual arousal can occur again Collaboration Management of men with ED ( growing in importance and scale Change in willingness to discuss sexuality and function Diagnostic tests Blood chemistry Hormone levels Nocturnal penile tumescence and rigidity monitoring Cavernosometry and cavernosography ( evaluate arterial inflow, venous outflow Pharmacologic therapy Oral medications Sildenafil citrate (Viagra) Vardenafil hydrochloride (Levitra) Tadalafil (Cialis) Injectable medications Hormone replacement therapy (HRT) ( testosterone injections, topical patches Injections into penis ( relaxes arterioles, smooth muscles of cavernosum ( inducing tumescence Mechanical devices Vacuum constriction device (VCD) Draws blood into penis ( traps there with band at base of penis Surgery Revascularization ( generally not successful Implantation of prosthetic devices See Figure 1911 TYPES OF PENILE IMPLANTS, p.1369 Client and partner teaching mandatory Nursing process Assessment Health history Physical examination Diagnosis Sexual Dysfunction Deficient Knowledge Situational Low Self-Esteem Planning Client will discuss concerns without embarrassment or anxiety Client will understand medication teaching aimed at preventing client from discontinuing necessary medications Client will understand treatment options and make an informed decision Implementation Discuss sexual dysfunction Assess for risk factors for erectile dysfunction Assess for sexual dysfunction Perform detailed assessment of current sexual practices Discuss previous methods of coping with erectile dysfunction Provide information about treatment options Promoteself-esteem Collect data If the man has had a penile implant, teach him and partner how to use the pump, including how to inflate and deflate the device Evaluation Client makes informed decision regarding treatment options Client understands that the problem is not related to his masculinity Review Erectile Dysfunction Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 19.2 Family Planning Overview Some of the most serious decisions relate to family planning and reproduction Contraception Decision to use contraception may be made individually or as a couple Should be made voluntarily with full knowledge of advantages, disadvantage, effectiveness, side effects, contraindications, and long-term effects Preconception counseling Making the decision to have children is first step a couple makes in process of conception Couples who wish to have children face decision about timing of pregnancy Religious beliefs that do not support contraception, fertility planning ( couples can still take steps to ensure that they are in best possible physical, mental health Preconception health measures Focus on helping couple attain best possible health state ( do not enter pregnancy with unnecessary risks Advise woman to stop or limit cigarette intake, exposure to secondhand smoke Avoid alcohol, caffeine, social and street drugs Discuss over-the-counter (OTC), prescription drugs with healthcare provider Preconception visit ( chronic health problems ( discuss medications, etc. Physical examination Advisable for both partners Dental exam, care prior to conception Nutrition Advisable for woman to be at average weight for body build and height Nutritious diet Folic acid supplementation Exercise Continue present pattern, establish regular exercise plan beginning at least 3 months before she attempts to get pregnant Immunizations Update immunizations prior to pregnancy Get yearly flu vaccine Infertility counseling Infertility ( lack of conception despite unprotected sexual intercourse for at least 12 months Profound emotional, psychologic, economic impact Subfertility Sterility Secondary fertility 1015 of couples in U.S. in reproductive years are infertile Elements essential for normal fertility Female partner Cervical mucus favorable Patent fallopian tube, normal fimbriae with peristaltic movements Ovaries must produce, release normal ova in regular, cyclic pattern No obstruction between ovaries and uterus Endometrium in physiological state to allow implantation of blastocyst, sustain normal growth Adequate reproductive hormones must be present Male partner Testes must produce spermatozoa of normal quality, quantity, motility Male genital tract must not be obstructed Male genital tract secretions must be normal Ejaculated spermatozoa must be deposited in female vaginal tract in such a manner that they reach the cervix Timing and environment ( crucial role See Table 194 POSSIBLE CAUSES OF INFERTILITY, p. 1373 Refer for infertility evaluation after 1 year of attempting to achieve pregnancy Earlier if positive history for fertility-lowering disease Advanced maternal age Genetics Desired, expected outcome of pregnancy ( healthy, perfect baby ( grief, fear, anger when baby born with defect, genetic disease Parents will have many questions Genetic disorders Hereditary material on strands of DNA ( chromosomes Somatic cells ( 46 chromosomes (diploid number) Sperm and egg ( 23 chromosomes (haploid number) 22 pairs ( autosomes (nonsex) 1 pair ( sex chromosomes Female 46 XX Male 46 XY Karyotype ( pictorial analysis of chromosomes ( blood, placental tissue Abnormalities ( autosomal or sex chromosomes Abnormalities of chromosomal number Most often caused by nondisjunction ( failure of paired chromosomes to separate during cell division Trisomies ( product of normal gamete with gamete that contains extra chromosome Down syndrome ( trisomy 21 ( See Figure 1912, KARYOTYPE OF A FEMALE WHO HAS TRISOMY 21, p. 1374 Monosomies ( product of normal gamete uniting with gamete missing a chromosome ( monosomy of entire autosomal chromosome incompatible with life Mosaicism ( occurs after fertilization ( results in individual who has two different cell lines See Table 19-5 CHROMOSOMAL SYNDROMES, p. 1375 Abnormalities of chromosome structure Translocation ( abnormal rearrangement of chromosomal material Carrier parent has 45 chromosomes, with one chromosome fused to another ( balanced translocation carrier Has child with partner with structurally normal chromosome constitution ( unbalanced translocation ( abnormal( Down syndrome Also caused by additions or deletions of chromosomal material Sex chromosome abnormalities In a female at early embryonic stage ( one of two normal X chromosomes ( inactive Forms a dark staining area ( Barr body Normal male has no Barr bodies ( only 1 X chromosome Most common ( Turner syndrome in females (45 XO with no Barr bodies present) Klinefelter syndrome in males (47, XXY with one Barr body present) Mosaic form of XO chromosome associated with daughters of women who took diethylstilbestrol (DES) during pregnancy Higher percentage of uterine malformation and hormonal difficulty Concern that children born as result of intracytoplasmic sperm injection (ICSI) might be at increased risk for chromosomal, other major congenital anomalies ( karyotyping and Y chromosome deletion analysis be offered to all men who are candidates for in vitro fertilization and ICSI Modes of inheritance Many inherited diseases produced by abnormality in single gene or pair of genes Mendelian (single-gene) inheritance and non-Mendelian (multifactorial) inheritance Observable expression of traits ( phenotype Total genetic makeup ( genotype One gene for trait from mother, one from father Homozygous or heterozygous Autosomal dominant inheritance Disease trait heterozygous ( abnormal gene overshadows normal gene of pair to produce trait Affected individual generally has an affected parent ( family pedigree usually shows multiple generation with disorder Affected individuals have 50 chance of passing on abnormal gene to each of their children Males and females equally affected Autosomal dominant inherited disorders have varying degrees of presentation Can have minimal expression in parent, severe effects in child See Figure 1914 AUTOSOMAL DOMINANT PEDIGREE, p. 1376 Autosomal recessive inheritance Individual must have two abnormal genes to be affected Carrier is individual who is heterozygous for the abnormal gene and clinically normal Affected individual may have clinically normal parents ( both parents are carriers of abnormal gene See Figure 1915 AUTOSOMAL RECESSIVE PEDIGREE, p. 1377 In the case in which both parents are carriers ( 25 chance that abnormal gene will be passed Each pregnancy has 25 chance of resulting in affected child Child of two carrier parents clinically normal ( 50 chance that child is carrier of gene Both males and females equally affected Increased history of consanguineous mating Sickle cell, phenylketonuria (PKU), cystic fibrosis, Tay-Sachs disease X-linked recessive inheritance Sex linked disorders ( abnormal gene carried on X chromosome No male-male transmission See Figure 1916 X-LINKED RECESSIVE PEDIGREE, p. 1377 50 chance that carrier mother will pass abnormal gene to each of sons ( be affected 50 chance that carrier mother will pass normal gene to each of sons ( unaffected 50 chance that carrier will pass abnormal gene to each of daughters ( become carriers Fathers affected with X-linked disorder cannot pass the disorder to sons ( ALL their daughters become carriers of the disorder Hemophilia, Duchenne muscular dystrophy, color blindness X-linked dominant inheritance Rare ( heterozygous females affected No male-male transmission Fragile X syndrome ( inherited form of mental retardation Multifactorial inheritance Many common congenital malformations ( interaction of many genes and environmental factors Cleft palate, heart defects, spina bifida, dislocated hips, clubfoot, pyloric stenosis The following occurs Malformations may vary from mild to severe Often a sex bias ( occurs more frequently in one sex In presence of environmental influences ( fewer genes needed to manifest disease in the offspring The more family members who have the defect ( greater the risk that the next pregnancy will be affected Careful family history should always be taken ( multifactorial, can be inherited as autosomal dominant or recessive traits Contraception Many couples use contraception ( plan and/or avoid conception Fertility awareness methods ( natural family planning Based on understanding of changes that occur throughout ovulatory cycle Free, safe, acceptable to many whose religious beliefs prohibit other methods Extensive counseling to be used effectively Calendar rhythm method ( based on assumptions that ovulation tends to occur about 14 days before start of next menstrual period AND sperm viable for up to 7 days AND ovum is viable for up to 3 days Least reliable method Basal body temperature (BBT) method ( requires women to take BBT every morning on awakening and before any activity ( record on a graph Method based on fact that temperature sometimes drops before ovulation and almost always rises and remains elevated for several days afterward See Figure 1917 SAMPLE BASAL BODY TEMPERATURE CHART, p. 1378 Couple abstains from intercourse on day of temperature rise and 3 days after Ovulation method (cervical mucus method, Billings method) ( assessment of cervical mucus changes that occur during menstrual cycle At time of ovulation ( mucus clearer, more stretchable (spinnbarkeit), more permeable to sperm Characteristic fern pattern on glass slide after drying Woman abstains from intercourse for first menstrual cycle ( assess cervical mucus for amount, feeling of slipperiness, wetness, color, clearness, spinnbarkeit Peak day of wetness, clear stretchable mucus ( time of ovulation Abstain from intercourse from time she first notices mucus becoming clear, more elastic ( until 4 days after last wet mucus Symptothermal method ( various assessments made and recorded by couple Cycle days Mucus changes Increased libido Mittelschmerz BBT Situational contraceptives Abstinence Coitus interruptus ( one of oldest and least reliable methods of contraception Douching after intercourse ( ineffective, may actually push sperm farther up the birth canal Spermicides Nonoxynol-9 (N-9) ( available as cream, jelly, foam, vaginal film, suppository Minimally effective when used alone ( increased effectiveness when used in conjunction with condom or diaphragm May irritate skin Does not offer protection against STIs, including HIV/AIDS Barrier methods Male and female condoms Male condoms Viable means of contraception when used consistently and properly Care must be taken in removing condom after intercourse Effectiveness largely determined by use Should not be stored in hot conditions ( accelerates deterioration Protects from STIs See Figure1918, AN UNROLLED CONDOM, p. 1380 Reality female condom ( thin polyurethane sheath with flexible ring at each end Closed ring fits over cervix ( open ring outside vagina, covers portion of perineum Diaphragm and cervical cap Diaphragm used with spermicidal cream or jelly ( good level of protection from conception Must be inserted before intercourse, with approximately 1 teaspoonful of spermicidal jelly placed around rim, in cup Diaphragm inserted through vagina, covers cervix Must leave diaphragm in place for at least 6 hours Must add spermicidal cream/jelly to vagina without disturbing placement of diaphragm Some couples feel use of diaphragm interferes with spontaneity of intercourse ( suggest insert as part of foreplay Excellent for women who are lactating, smokers, or cannot or do not wish to use oral contraceptive (OC) Silicone available for women with latex allergy Women who object to touching genitals may find this method unsatisfactory Very obese, short fingers ( difficulty inserting, checking placement History of UTIs ( pressure may interfere with complete bladder emptying See Figure 1920 INSERTING THE DIAPHRAGM, p. 1381 Cervical cap ( latex cup-shaped device used with spermicidal cream or jelly (fits snugly over cervix, held in place by suction Cap may be left in place for 48 hours May be more difficult to fit, insert because of size Similar advantages, disadvantages, contraindications as diaphragm Leas shield ( reusable silicone vaginal barrier method that completely covers cervix Similar to cervical cap ( valve that permits passage of secretions and air Vaginal sponge Pillow-shaped, soft, absorbent synthetic sponge containing spermicide Concave area on one side ( fits over cervix Left in place for 6 hours following intercourse ( up to 24 hours Removed ( discarded Over the counter, professional fitting not required, may be used for multiple acts of coitus Difficulty removing, allergic reactions, irritation Intrauterine contraception IUC ( safe, effective method of reversible contraception Inserted into uterus by qualified healthcare provider ( left in place for extended period High rate of effectiveness, continuous contraception protection, no coitus-related activity, relative inexpensiveness over time Possible discomfort to wearer, increased bleeding during menses, perforation of uterus during insertion, intermenstrual bleeding Copper T380A ( nonhormonal, highly effective, left in place up to 10 years Levonorgestrel-releasing intrauterine system ( small T-shaped frame with reservoir that releases hormone gradually Comparable in effectiveness to Copper T380A, left in place up to 5 years Formerly recommended for women who had at least one child, stable mutually monogamous relationship Changed ( effective and reliable for women who have never been pregnant Inserted into uterus with string or tail protruding through the cervix into the vagina Clinician instructs to check for presence of string once a week for first month ( then after menses May have cramping, bleeding for 26 weeks Contact provider if exposed to STI, late period, abnormal spotting, bleeding, pain with intercourse, abdominal pain, abnormal discharge, signs of infection, missing string Hormonal contraceptives Inhibit release of ovum, create atrophic endometrium, maintain thick cervical mucus that close transport, inhibits process that allows sperm to penetrate ovum Combined estrogen-progestin approaches Combined oral contraceptives (COC) ( safe, highly effective, rapidly reversible Taken daily for 21 days ( stop (or placebo) for 7 days ( restart Menses 14 days after last pill Research ( 217 approaches may need to be modified Extended cycle COC 91-day regimen ( active pill for 84 days ( inactive pill for 7 Variety of side effects See Table 196 SIDE EFFECTS ASSOCIATED WITH ORAL CONTRACEPTIVES, p. 1384 Absolute contraindications Pregnancy History of thrombophlebitis Acute, chronic liver disease of cholestatic type Presence of estrogen-dependent carcinomas Undiagnosed uterine bleeding Heavy smoking Gallbladder disease Hypertension Diabetes Hyperlipidemia Noncontraceptive benefits ( relief of uncomfortable menstrual symptoms Progestin-only pill ( safe for nursing mothers Other combined hormonal methods Transdermal patch ( highly effective in women who weigh less than 198 pounds Skin absorption of transdermal estrogen 60 greater than oral absorption Vaginal contraceptive ring (NuvaRing) Low dose, sustained-release hormonal contraceptive is flexible, soft ring that woman inserts into vagina Left in place for 3 weeks Lunelle ( injectable combination off the market in U.S. and Canada Long-acting progestin contraceptives Capsules containing progestin implanted in womans arm None available in U.S. at this time Prevents ovulation in most women Minor surgical procedure necessary for insert and removal Depot-medroxyprogesterone acetate (Depo-Provera) ( highly effective birth control for 3 months when given as single injection Suppresses ovulation Not recommended for use longer than 2 years ( associated with calcium loss from bones that may not resolve after discontinuing use Depo-Provera 104 ( subcutaneous injection Emergency contraception (EC)( indicated when woman worried about pregnancy ( contraception failure, unprotected intercourse, rape Two doses First, no longer than 72 hours after intercourse Second, 12 hours later COCs can be used ( consult healthcare provider about specifics Placement of copper IUC within 5 days of unprotected intercourse may reduce pregnancy risk Operative sterilization Inclusive term ( permanently prevent pregnancy Counseling important for both partners Vasectomy ( male ( surgically severing vas deferens in both sides of scrotum Recheck sperm count ( 6, 12 months Side effects ( pain, infection, hematoma, sperm granulomas, spontaneous reanastomosis Sometimes surgically reversible Tubal ligation ( female ( fallopian tubes clipped, ligated, electrocoagulated, banded, or plugged Complications possible ( coagulation burns, perforation of bowel, pain, infection, hemorrhage, adverse anesthesia effects Essure ( stainless steel microinserts placed in tubes ( stimulating growth of local tissue ( results in tubal blockage Specialized training Hysterosalpingogram (HSG) 3 months postprocedure to confirm occlusion Male contraception Vasectomy and condom ( only forms of male contraception available in U.S. Discontinuing contraception Woman using hormonal contraception ( advised to stop hormonal birth control method, have 2 or 3 normal menstrual cycles before attempting to conceive Women who have used Depo-Provera ( advise that it could take up to 12 months to conceive after discontinuation Collaboration Involves several members of healthcare team ( geneticists, psychologists, infertility experts Diagnostic tests BBT recording Hormonal assessments of ovulatory function Endometrial biopsy Transvaginal ultrasound HSG Hysteroscopy Laparoscopy Diagnostic tests for potential genetic issues include following Genetic screening Genetic ultrasound Genetic amniocentesis Percutaneous umbilical cord sampling and chorionic villus sampling Alpha-fetoprotein (AFP) Preimplantation genetic testing Fertility medications Pharmacologic agents are commonly used ( ovarian stimulation in follicular phase, control of midcycle release, support of luteal phase See Table 197 DRUGS COMMONLY USED TO TREAT INFERTILITY, p. 1387 Clinical interruption of pregnancy Abortion legalized in 1973 ( associated controversy over moral, legal issues continues Some people are strongly opposed to abortion for religious, ethical, personal reasons ( others feel access to safe, legal abortion is every womans right Medical abortion provides effective alternative to surgical abortion Mifepristone (RU486, Mifeprex) ( induces abortion up to 49 days following conception Blocks action of progesterone ( alters endometrium After gestation confirmed ( first dose 13 days later ( dose of misoprostol ( prostaglandin that induces contractions ( expel embryo Possible connection with 7 deaths ( warnings with patient teaching Surgical abortion ( DC, minisuction, vacuum curettage in first trimester Risks ( perforation of uterus, laceration of cervix, anesthesia reaction, hemorrhage, infection Second trimester abortion ( DE, hypertonic saline, systemic prostaglandins, intrauterine prostaglandins Therapeutic insemination ( depositing of semen at cervical os or in the uterus by mechanical means Therapeutic donor inseminations (TDI) ( use of donor semen Therapeutic husband inseminations (THI) ( use of husbands semen Usual indications( THI Oligospermia Asthenospermia Teratospermia Anatomic defects ( hypospadias Ejaculatory dysfunction ( retrograde ejaculation Usual indications ( TDI Azoospermia Severe oligospermia Severe asthenospermia Inherited male sex-linked disorder Autosomal dominant disorders TDI ( more complicated, expensive ( need for strict screening, processing procedures Numerous factors to be evaluated before TDI performed In vitro fertilization (IVF) IVF ( selectively used in cases when infertility has resulted from tubal factors, mucus abnormalities, male infertility, unexplained infertility, male/female immunological infertility, cervical factors Womans eggs collected from ovaries ( fertilized in laboratory ( placed in uterus after normal development has begun Potential for successful pregnancy with IVF maximized when 3 to 4 embryos placed in uterus Fertility drugs used to induce ovulation Egg retrieval performed by transvaginal approach under ultrasound guidance See Figure 1924 TRANSVAGINAL ULTRASOUND-GUIDED..., p. 1389 Outpatient procedure Sperm used to fertilized eggs in vitro ( naturally, microsurgical epididymal sperm aspiration (MESA) or testicular sperm aspiration (TESA) Successful IVF ( depends on many factors, especially age, indication Other assisted reproduction techniques Transfer of gametes, zygotes, embryos Cryopreservation IVF using donor oocytes Micromanipulation techniques Use of gestational carrier See Figure 1925 ASSISTED REPRODUCTIVE TECHNIQUES, p. 1390 Preimplantion genetic diagnosis Other recent advances in micromanipulation allow single cell to be removed from embryo for genetic study Blastomere analysis Preimplantation genetic diagnosis (PGD) Diagnosis of genetic disorders before implantation provide couples with option of forgoing attempt to establish pregnancy ( avoiding decision about terminating affected pregnancy Identification of couples at risk Availability or and access to centers providing PGD Analysis of blastomeres for sex chromosome testing when genetic disorder suspected Identification of late-onset diseases Effect on offspring as result of removing cells from embryo Selection for nonmedical reasons and potential concern of eugenics designer babies Assisted embryo hatching ( adjunct therapy in IVF IFV using gestational carrier ( infertile women genetically sound ( unable to carry pregnancy Genetic counseling referral Genetic counseling ( communication process in which genetic counselor, physician, specially trained and certified nurse try to provide family accurate, complete information about occurrence or risk of recurrent of genetic disease in family Advised for any of following Congenital abnormalities, including mental retardation Familial disorders Known inherited diseases Metabolic disorders Chromosomal abnormalities Genetic counselor creates pedigree with information from family Facilitate identification of other family members who might be at risk Nursing process Assessment Nonjudgmental attitude, open communication, matter-of-fact attitude Questions for both genders Ask about history of sexual activity, including the age at first sexual intercourse Ask about the number of sexual partners, currently and in the past Ask about the use of contraceptives Ask about the use of barriers to prevent STIs Ask about a history of sexual trauma, including abuse, rape, or incest Women Ask about risk factors for breast cancer, including family history Ask about breast self-exam, how often she does it, and any abnormal findings Perform a breast examination, palpating the breast for masses, irregularities in contour, and drainage, if warranted Ask about menstrual history, including onset of menstruation, the date of the last menses, and any irregularities Men Ask about testicular self-examination, how often he does it, and any abnormal findings. Perform a testicular examination, palpating for masses and inspecting the genitals for lesions and drainage, if warranted Ask about difficulty voiding, including difficulty starting or stopping and the size of the stream Ask about sexual functioning, including premature ejaculation, impotence, or other sexual problems Diagnosis Risk for Disturbed Body Image Sexual Dysfunction Deficient Knowledge Planning Client describes options available for treatment ( picks option that best fits his/her needs, beliefs, values Client acknowledges impact of situation on existing personal relationships and lifestyle Client describes actual change in body function Client maintains close social interactions and personal relationships Implementation Promote healthy body image Encourage verbalization of feelings Provide resources as appropriate Teach client (and significant other, if appropriate) about reproductive physiology as it applies to use of contraceptive, infertility or genetic issue Promote healthy sexual function Encourage discussion of sexual function among client, partner, healthcare provider Provide information given by healthcare provider regarding treatment options Encourage client to discuss concerns of sexuality with therapist or counselor Discuss knowledge of sexual and reproductive health Teach clients about risk factors for reproductive dysfunction Teach clients about disease prevention Teach clients about their specific disease and prescribed treatment Evaluation Client makes informed decisions about treatment based on the disorder and individual choice Client verbalizes understanding of information presented Client expresses feelings openly Review Family Planning Relate Link the Concepts and Exemplar Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 19.3 Menopause Overview Menopause ( permanent cessation of menses Climacteric, perimenopausal ( time during which reproductive function gradually ceases Neither disease or disorder ( normal physiological process Physiology and etiology Marks natural biological end of reproductive ability Surgical menopause ( ovaries removed in premenopausal women Chemical menopause ( medications arrest ovarian function Ovarian function decreases ( production of estradiol (E2) decreases, ultimately replaced by estrone Clinical manifestations Age-related ( not pathology Some women have troublesome health experiences Breast tissue, body hair, skin elasticity, and subcutaneous fat decrease Ovaries, uterus, cervix, and vagina decrease in size Vaginal dryness, dyspareunia, urinary stress incontinence, and UTIs Hot flashes, palpitations, dizziness, and headaches Insomnia, frequent awakening, night sweats Osteoporosis and increased cardiovascular disease Irritability, anxiety, and depression Long-term estrogen deprivation results in imbalance in bone remodeling, osteoporosis ( leading to fractures, kyphosis Some women celebrate menopause others may experience negative feelings others may attach no significance to it See Box 195 MANIFESTATIONS OF THE PERIMENOPAUSAL PERIOD, p. 1395 Collaboration Diagnostic tests Follicle-stimulating hormone (FSH), LH rise and remain elevated as estrogen secretion decreases ( Serum FSH or no menstruation for 1 full year ( menopausal Pharmacologic therapy HRT ( may be prescribed to alleviate severe manifestations of menopause ( limited amount of time, and only after woman has been provided with known risks Selective estrogen receptor modulators (SERMs) bind to estrogen receptors ( bind to estrogen receptors, exert site-specific effects in different target issues Ralozifene (Evista) Triphenylethylene (Tamoxifen) Until recently HRT common ( American Heart Association (AHA) advised to stop prescribing HRT for cardioprotection Menopausal women may be anxious about using estrogen-containing preparations Alternative and complementary therapy As result of controversy surrounding use of HRT ( nontraditional, alternative therapies have become more popular Acupuncture Massage Botanicals Supplements Bioidentical hormones Meditation and yoga Nursing process Focus on minimizing symptoms associated with hormonal changes Reducing risks of disease processes Education Resources National Institute on Aging Centers for Disease Control and Prevention North American Menopause Society Association of Reproductive Health Professionals Womens Health Initiative National Womens Health Information Center Assessment Health history Physical assessment Diagnosis Deficient Knowledge Ineffective Sexuality Pattern Situational Self-Esteem Disturbed Body Image Planning Client will understand process of menopause Client will learn strategies to reduce and cope with symptoms Client will undertake program of weight-bearing exercises Implementation Discuss knowledge of menopause Discuss physiological manifestations, such as hot flashes and night sweats Provide information about dietary recommendations Emphasize the importance of weight-bearing exercise Provide information about the benefits and risks of HRT Encourage the woman to obtain yearly mammograms, clinical breast examinations, and Pap smears, to perform monthly breast self-examination on same day each month Promote effective sexuality pattern Encourage expression of feelings and concerns about how menopause is changing her sex life Suggest ways to increase vaginal lubrication Explain that as women age, it may take longer for vaginal lubrication and orgasm to occur Promote self-esteem Encourage expression of fears and concerns related to changes in interpersonal and family functions Suggest volunteer activities or employment for the woman who has extra time Discuss importance of healthy lifestyle in maintaining physical attractiveness Promote healthy body image Encourage woman to describe her perceptions of her own body Encourage verbalization of feelings of concern, anger, anxiety, loss, fear over body changes Stress that certain physical characteristics cannot be changed emphasize importance of learning to recognize and appreciate ones own special strengths Refer as appropriate for dietary management, exercise, stress management, cosmetic assistance Evaluation Client demonstrates positive sense of self as evidenced by stable weight, participation in regular exercise program, ability to manage stress Client verbalizes feelings related to changes that have occurred Client describes strategies for maintaining health Review Menopause Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 19.4 Menstrual Dysfunction Overview Monthly menstruation ( normally involves some minor discomforts Some women experience more serous changes in the menstrual cycle Pain Bleeding Pathophysiology, etiology, and clinical manifestations Dysmenorrhea ( pain associated with menses Primary dysmenorrhea ( begins within first 3 or 4 menstrual periods and continues during teens and twenties See Box 19-6 MANISFESTATIONS OF PRIMARY DYSMENORRHEA, p. 1400 Secondary dysmenorrhea ( related to pathology or diseases occurs in women ages 30 50 Endometriosis ( cells from endometrial tissue implant and grow outside the uterus, usually to organs in the lower part of the pelvis Dysmenorrhea worsens each month Dyspareunia Menorrhagia Postcoital bleeding Urinary complaints Rectal pain Tumors Cysts Pelvic adhesions Pelvic inflammatory disease Infections Cervical stenosis Uterine leiomyomas Adenomyosis Dysfunctional uterine bleeding (DUB)( bleeding from all causes Amenorrhea ( absence of menstruation Oligomenorrhea (scant) ( usually related to hormonal imbalances Menorrhagia ( excessive or prolonged menstruation ( thyroid disorders, endometriosis, pelvic inflammatory disease (PID), functional ovarian cysts, uterine fibroids or polyps Metrorrhagia ( bleeding between menstrual periods ( hormonal imbalances, PID, cervical or uterine polyps, uterine fibroids, cervical or uterine cancer Postmenopausal bleeding ( endometriosis, polyps, endometrial hyperplasia, uterine cancer Risk factors Stress Extreme weight changes Use of oral contraceptives or an IUC device DUB usually related to hormonal imbalances Collaboration Focus on identifying underlying cause, reestablishing functional capacity, managing pain Careful history and assessment performed to rule out underlying organic cause Diagnostic tests Identify structural abnormalities, hormonal imbalances, pathological conditions Findings from pelvic examination Pap smear Cervical, vaginal cultures Ultrasound of pelvis, vagina CT scan, MRI FSH, LH Progesterone, estradiol levels Thyroid function tests Laparoscopy ( used to diagnose structural defects, blockages See Figure 1927 LAPAROSCOPY, p.1402 Hysteroscopy Endometrial biopsy CBC Endocrine studies Pharmacologic therapy Dysmenorrhea ( analgesics, NSAIDs, oral contraceptives DUB ( hormonal agents Ovulatory DUB ( progestins during luteal phase Oral iron ( replace iron lost through menstrual bleeding Diuretics ( to relieve bloating SSRIs ( to manage mood or help client cope with chronic pelvic pain Surgery Emphasizes least invasive method that provides effective relief Therapeutic DC Cervical canal dilated, uterine wall scraped Endometrial ablation Endometrial layer of uterus permanently destroyed using laser surgery or electrosurgical resection Hysterectomy Removal of uterus when medical management of bleeding disorders unsuccessful or malignancy present See Box 19-8 NURSING CARE OF THE CLIENT HAVING A HYSTERECTOMY, p. 1403 Abdominal hysterectomy Performed when preexisting abdominal scar present, adhesions, large operating field necessary Vaginal hysterectomy Removal of uterus though the vagina Desirable when uterus descended into vagina, urinary bladder or rectum prolapsed into vagina Alternative and complementary therapies Focus on diet, exercise, relaxation, and stress management Rose hips Fish oil plus B12 Vitamin E and magnesium Nursing process Assessment Nursing history Last menstrual period Open communication Subjective data Objective data Physical examination Diagnosis Acute Pain Ineffective Coping Anxiety Risk for Ineffective Perfusion Fatigue Sexual Dysfunction Planning Clients pain and discomfort will be reduced to an acceptable level Client will experience physical comfort and energy-saving rest Client will increase intake of fluids and iron-rich foods Client will become more comfortable discussing sexual dysfunction Client will identify coping strategies to reduce anxiety Client will maintain a journal of symptoms Implementation Relieve acute pain Teach effective pharmacologic, nonpharmacologic self-care measures to relieve pain Review daily activities and suggest ways to balance rest periods and activity Review manifestations and correlate with dietary patterns, activity levels if possible If appropriate, suggest sexual activity as a way to lessen menstrual cramps Relieve anxiety Discuss results of tests and examinations with the woman Provide information about causes, treatments, risks, long-term effects of treatments, and prognosis Evaluate coping strategies and psychosocial support systems Promote sexual function Offer information about engaging in sexual activity during menstruation Provide opportunity for expression of concerns related to alterations in lifestyle and sexual functioning Encourage frequent rest periods Provide information about alternative methods of sexual expression Evaluation Client experiences less pain, allowing her to perform activities of daily living Client experiences less fatigue Client reports reduced anxiety Client reports return to baseline menstruation Client is able to participate in sexual activity without symptoms Review Menstrual Dysfunction Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 19.5 Responsible Sexual Behavior Overview Increase in incidence of sexually transmitted infections (STIs) HIV/acquired immunodeficiency syndrome (AIDS), genital herpes All sexually active individuals need to know how to reduce spread of STIs Safer sex Reducing number of sexual partners Should not engage in unprotected sex Latex condoms Nonoxynol-9 as lubricant See Box 199 GUIDELINES FOR SAFER SEX, p. 1407 Dating violence Another type of intimate partner abuse Most directed at females May lead to other risk behaviors Date rape Harmful to females who often do not want to discuss event, or press charges See Box 1910 EARLY WARNING SIGNS OF TEENAGE DATING VIOLENCE, p. 1407 Review Responsible Sexual Behavior Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 19.6 Sexually Transmitted Infections Overview Infections transmitted by vaginal, oral, anal intimate contact and intercourse ( sexually transmitted infections (STIs) Includes those cause by bacteria, Chlamydia, viruses, fungi, protozoa, parasites Incidence and prevalence STIs ( epidemic proportions in U.S., increasing worldwide See Box 1911 SELECTED FACTS ABOUT SEXUALLY TRANSMITTED INFECTIONS, p. 1409 Women and infants disproportionately affected by STIs Adolescents considered an at-risk population Incidence of STIs ( highest in young adults ages 1524, minorities Emergence of HIV/AIDS ( epidemiological synergy among all STIs Characteristics Several characteristics in common Most can be prevented by use of latex condoms Can be transmitted during both heterosexual, homosexual activities, including nonpenetrating intimate exposure For treatment to be effective ( sexual partners of infected person must also be treated Two or more STIs frequently coexist in same client Prevention and control Preventions and control of STIs based on principles of education, detection, effective diagnosis, treatment of infected persons, evaluation treatment, counseling of sex partners of people infected Collect accurate sexual history using the Five Ps Partners Prevention of pregnancy Protection from STIs Practice Past history of STIs Most effective way to prevent sexual transmission of HIV, other STIs ( avoid sexual intercourse with infected partner Common sexually transmitted infections Genital herpes Caused by herpes simplex viruses HSV-1 and HSV-2 Pathophysiology One hundred types of HSV viruses identified ( more than 30 affecting urogenital area Moves into stratified squamous epithelium ( infects neurons that innervate Manifestations 210 days after exposure ( painful red papules appear on genital area Soon after papules appear ( form small painful blisters filled with clear fluid containing particles See Figure 1928 GENITAL HERPES BLISTERS, p. 1410 First outbreak of herpes lesions ( first episode infection ( average duration of 12 days Recurrent infections ( 45 days, less severe See Box 1914 MANIFESTATIONS OF GENITAL HERPES, p. 1411 Presumptive diagnosis based on history and physical examination of client ( lesions, patterns of recurrence Diagnosis and treatment History and physical exam Diagnostic tests Virological tests are available Pharmacologic therapy Acyclovir (Zovirax) helps reduce length and severity of first episode, treatment of choice for genital herpes Other antivirals ( Foscavir, Valtrex, Famvir Human papillomavirus Genital warts caused by human papillomavirus (HPV) ( most common genital infection in U.S. Women at greater risk ( larger mucosal surface area exposed in genital area Majority of people infected with genital warts asymptomatic Pathophysiology HPV ( transmitted by vaginal, anal, oral-genital contact Incubation period 2 3 months See Box 1915 SELECTED FACTS ABOUT GENITAL HPV INFECTION, p. 1411 Manifestations Characteristic lesions ( single, multiple painless, soft, moist, pink, flesh-colored swellings in vulvovaginal area, perineum, penis, urethra anus, groin or thigh In women ( may be apparent during pelvic examinations Diagnosis and treatment Based on clinical appearance Pap tests identify precancerous lesions on cervix Treatment in early stages will prevent cancer Pharmacologic therapy Warts removed with treatments applied by healthcare provider or client Imiquimod (immune response modifier) ( client applied Podophyllum, trichloroacetic acid ( provider-administered treatments Gardasil and Cervarix( vaccine developed to prevent genital warts Other treatments Removed by cryotherapy, electrocautery, laser vaporization Chlamydia Group of STIs caused by Chlamydia trachomatis bacterium that behaves like virus Chlamydia ( most commonly reported bacterial STI in U.S. Asymptomatic in most women ( until uterus, fallopian tubes have been invaded See Box 1916 RISK FACTORS FOR CHLAMYDIAL INFECTION, p. 1412 Nearly one third of men with urethral Chlamydia asymptomatic Leading cause of preventable blindness in newborn Pathophysiology C. trachomatis intracellular bacterial pathogen ( resembles both virus, bacterium Manifestations Incubation period ( 13 weeks May be present for months, years ( without symptoms in women Still potentially infectious Complications Untreated ( ascends into upper reproductive tract ( PID Infertility, ectopic pregnancy Diagnosis and treatment Tests for antibodies ( PCR or nucleic acid hybridization test Treated with antibiotics Pharmacologic therapy CDC recommends ( azithromycin (Zithromax), doxycycline (Adoxa) Both partners must be treated at same time or prior to resuming sexual intercourse Gonorrhea Known as GC ( caused by Neisseria gonorrhoeae ( Gram-negative diplococcus Rates for African Americans 30 higher than rates for non-Hispanic Whites Pathophysiology Pyogenic bacteria that causes inflammation In men ( acute painful epididymus, periurethral glands ( lead to sterility In women ( PID, endometritis, salpingitis, pelvic peritonitis Manifestations In men ( dysuria, serous, milky or purulent discharge from penis In women ( dysuria, urinary frequency, abnormal menses, increased vaginal discharge, dyspareunia Homosexual men ( anorectal gonorrhea Pruritis, mucopurulent rectal discharge, rectal bleeding, pain, constipation Gonococcal pharyngitis Complications PID in women ( internal abscesses, chronic pain, ectopic pregnancy, infertility Blindness, infection of joints, potentially lethal infections of blood in newborn Epididymitis and prostatitis in men ( infertility and dysuria Spread of infection to blood and joints Increased susceptibility to and transmission of HIV Diagnosis and treatment Diagnosis obtained via cultures from infected mucous membranes Goals of treatment ( include eradication of organism, any coexisting disease and prevention of reinfection or transmission Nurse must emphasize compliance with medication regimen and abstaining from sexual contact until infection is cured in client and partners Condom use to prevent future infection is essential Syphilis Complex systemic STI ( spirochete Treponema pallidum Transmitted during any sexual contact Rates rising since 1996 ( urban centers Pathophysiology Any break in skin, mucous membrane vulnerable ( spread through blood, lymphatic system Congenital syphilis ( transferred to fetus through placental circulation Manifestations Primary syphilis Appearance of chancre, regional enlargement of lymph nodes, little or no pain ( 34 weeks after infectious contact Highly infectious Secondary syphilis Appears any time from 2 to 6 months after initial chancre disappears Skin rash, mucous patches in oral cavity, sore throat, generalized lymphadenopathy, condyloma lata, flulike symptoms, alopecia Latent and tertiary syphilis 2 or more years after initial infection ( last up to 50 years Transmitted by infected blood, NOT sexual contact Two types of late-stage syphilis Benign late syphilis ( generally responds promptly to treatment Diffuse inflammatory response ( can be treated, but much of cardiovascular and CNS damage irreversible Diagnosis and treatment Goals of treatment ( inactivate spirochete, educate client about how to prevent reinfection or further transmission Diagnostic tests Venereal Disease Research Laboratory (VDRL) ( 46 weeks after infection FTA-ABS specific for T. pallidum ( confirm VDRL and rapid plasma reagin (RPR) findings Pharmacologic therapy Treatment of choice ( penicillin G, IM in single dose Treatment may result in severe reaction ( Jarisch-Herxheimer reaction Reaction to sudden, massive destruction of spirochetes by penicillin and resulting release of toxins into blood stream Nursing process Assessment Focused interview of female Data collection ( sexual practices, health history Information about genital areas, reproduction, sexual activity ( private Physical assessment Guided by focused interview Reports of pain Discharge, inflammation Diagnosis Acute Pain Sexual Dysfunction Knowledge Deficit Planning Client will describe strategies for reducing risk of contracting an STI Client will develop plan to contact anyone who may have been exposed to the diagnosed STI through sexual contact Client will abstain from sexual activity until STI resolved, or take appropriate actions to avoid infecting others Clients pain is controlled to reduce severity of pain to a tolerable level Implementation Relieve acute pain Oral analgesics Teach client how to keep herpes blisters clean and dry For dysuria, suggest pouring water over the genitals while urinating Suggest use of sitz baths for 1530 minutes several times a day Discuss sexual function Provide supportive, nonjudgmental environment for client to discuss feelings and ask questions about what this diagnosis means to future sexual relationships Offer information about support groups and other resources for people with herpes, such as National Herpes Information Hotline Discuss disease management How to recognize prodromal symptoms of recurrence and factors that seem to trigger recurrences Need for abstinence from sexual contact from the time prodromal symptoms appear until 10 days after all lesions have healed If lesions become infected, use of topical acyclovir Use of latex condoms due to viral shedding at any time and careful hygiene practices Need for prompt treatment and necessity for sexual abstinence until lesions healed or using condom while lesions are present The need to discuss herpes infections with significant other Importance of thorough hand washing Evaluation Resolution of the STI Client explains strategies to prevent infection of others Client abstains from sexual activity until STI is treated Client describes barrier methods to reduce risk of contracting an STI Review STIs Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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