Ob Final Exam Review Summary Maternity Nursing

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OB Final Exam Review - Summary Maternity Nursing
Medical Surgical 1 ( Chamberlain University)
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OB final Exam Review

Chapter 4
Menstrual disorder vocabulary
 Meno= menstrual related
 Metro= Time
 Oligo = few
 A= without, none, or lack of
 Rhagia- excess or abnormal
 Dys= not or pain
 Rhea= flow
Menstrual Disorders
 Amenorrhea
 Dysmenorrhea
 Abnormal uterine bleeding (AUB)
 Premenstrual syndrome (PMS)
 Premenstrual dysphoric disorder (PMDD)
 Endometriosis
Amenorrhea- simply means absence of menses.
 Primary amenorrhea – is defined as either the:
Absence of menses by age 14, with absence of growth and development of secondary sex
characteristics.
Or
Absence of menses by age 16, with normal development of secondary sex characteristics.
 Secondary amenorrhea – is the absence of regular menses for three cycles or irregular
menses for 6 months in women who have previously menstruated regularly.
Primary and secondary causes of amenorrhea page 116-117
 Therapeutic management:
 primary amenorrhea involves correction of the underlying disorders and estrogen
replacement therapy to stimulate development of secondary sex characteristics.
 Secondary amenorrhea – oral contraceptives (cyclic progesterone), bromocriptine
to treat Hyperprolactinemia, nutritional counseling.
The Tanner stages
 Stage 1- Papilla elevation only
 Stage 2- Breast buds palpable and areolae enlarge -11 years old
 Stage 3- Elevation of breast contour, areolae enlarge – 12 years old
 Stage 4- Areolae forms secondary mound on the breast -13 years old

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 Stage 5- Adult breast contour; areola recess to breast contour.

Dysmenorrhea – refers to painful menstruation and is a common problem in adolescence. (cyclic
perimenstrual pain)
 Usually pain starts along with bleeding and last for 48-72 hours.
 Caused by increased prostaglandin production by the endometrium an ovulatory cycle.
 Secondary dysmenorrhea (congestive) – is painful menstruation due to pelvic or uterine
pathology.
 Endometriosis is the most common cause of secondary dysmenorrhea.
 The goal of treatment is to provide adequate pain relief.
 Suppressing the endometrium if endometriosis is suspected is achieved by OCs (depo-
provera)
Treatment options for Dysmenorrhea Table 4.1 pg 120
 NSAIDs – prevent prostaglandin synthesis (ibuprofen, Naproxen) reducing cramping.
Take with meals, Do not take with aspirin, avoid alcohol, watch for signs of GI bleeding
 Hormonal Contraceptives – decrease prostaglandin synthesis; SECOND LINE
TREATMENT (Depo-Provera, Low dose oral contraceptives)
 Selective estrogen receptor modulators (SERMs) – used for women not responding to
NSAIDs and OCs. Adverse effects- hot flashes, nausea, vomiting, risk for
thromboembolism
 Complementary therapies – Thiamine (vit B), Vit E (tocopherols), Magnesium, omega 3
 Life style changes – daily exercise, limited salty foods, wt loss, smoking cessation,
relaxation tech.
Teaching Guidelines (managing dysmenorrhea)
 Exercise to increase endorphins and suppress prostaglandin release.
 Limit salty foods to prevent fluid retention.
 Increase water consumption to serve as a natural diuretic (vit B-6 works as well)
 Increase fiber intake with fruits and veggies, to prevent constipation.
 Use heating pads or warm baths to increase comfort.
 Take warm showers to promote relaxation.
 Sip warm beverages, such as decaffeinated green tea
 Keep legs elevated while lying down or lie on side with knees bent.
 Use stress management.
 Stop smoking.
Abnormal uterine bleeding (AUB) – disturbances of menstrual bleeding. It is an umbrella term.
 Disorder that occurs most frequently in women at the beginning and end of the
reproductive years.
 Causes are related to hormone disturbances.
 Menorrhagia – abnormally long, heavy periods.
 Oligomenorrhea – less frequent bleeding, intervals of more than days/

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 Metrorrhagia – bleeding between periods

 Menometrorrhagia- excessive uterine bleeding (lasting more than 7 days)
 Polymenorrhagia – too frequent periods.
 Causes = pg 112 under etiology.
 Treatment options – combine OCs, NSAIDs, tranexamic acid (antifibrinolytic)
Drug categories
 Estrogens – cause vasospasm of the uterine arteries to decrease bleeding.
 Progestins – used to stabilize an estrogen-primed endometrium
 OCs- regulate the cycle and suppress the endometrium
 NSAIDs- inhibit prostaglandins in ovulatory menses cycle
 Progesterone-releasing – suppress endometrial growth
 Antifibrinolytic drugs – prevent fibrin degradation to reduce bleeding
 Iron replacement therapy – replenish iron stores lost during heavy bleeding.
If client does not respond to medical therapy surgical intervention might be necessary.
 Dilation and curettage D&C
 Endometrial ablation
 Uterine artery embolization
 Hysterectomy.
 Clinical manifestations of AUB – vaginal bleeding between periods, irregular menstrual
cycles (usually less than 28 days) infertility, mood swings, hot flashes, vaginal
tenderness.
Concept mastery alert – treatments for premenstrual syndrome- possible treatment options for
PMS include reduction of caffeine intake, vitamin and mineral supplements, diuretic therapy,
and NSAIDs. Medications that have found to be helpful with PMS – antidepressants and
anxiolytics.
Take Note – complications such as infertility can result from lack of ovulation, severe anemia
can result secondary to prolonged heavy menses, depression and embarrassment may be
secondary to the irregular and heavy bleeding.
Premenstrual syndrome (PMS) – constellation of recurrent symptoms that occur during the luteal
phase or last half of the menstrual cycle and resolve with onset of menstruation.
ACOG defines PMS as “the cyclin occurrence of symptoms that are sufficiently severe to
interfere with some aspect of life, and that appear with consistent and predictable relationship to
menses.
Take Note – because there are no DX test that can reliably determine the existence of PMS or
PMDD, the women herself must decide that she needs help during this time.
Therapeutic management for PMS and PMDD- address symptoms; treatments can include
vitamin supplements, diet changes, exercise, lifestyle changes, and medications.

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Box 4.2 Treatment options for PMS and PMDD

Lifestyle changes –
 Reduce stress
 Exercise 3-5 times a week
 Eat a balanced diet & increase water intake
 Decrease caffeine intake
 Stop smoking
 Limit alcohol
Vitamin and mineral supplements –
 Multi vitamins
 Vit E 400 unites
 Calcium 1200-1600 mg
 Magnesium 200-400 mg
Medications
 NSAIDs taken a week prior to menses
 OCs (low dose)
 Antidepressants (SSRI)
 Diuretics to remove excess fluid
 Progestins
 GnRH
 Danazol
Symptoms
 A- anxiety: difficulty sleeping, tension, mood swings, and clumsiness
 C- cravings: craving sweet, salty foods, chocolate
 D- depression: feelings of low self-esteem, anger, easily upset.
 H- Hydration – weight gain, abdominal bloating, breast tenderness
 O- other – hot flashes, cold sweats, nausea, change in bowel habits, aches, and pains,
acne breakout.
ACOG criteria for PMS – having at least one of the following affective and somatic symptoms
during the 5 days prior to menses
 Affective symptoms – depression, anger outburst, irritability, anxiety
 Somatic symptoms – breast tenderness, abdominal bloating, edema, headaches
ACOG criteria for PMDD – having at least 5 typical symptoms; must occur the week before and
few days after onset of menses
 Affective lability: sadness, tearfulness, irritability
 Anxiety tension
 Persistent or marked anger or irritability

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 Depressed mood, feeling or hopelessness

 Difficulty concentrating
 Chronic fatigue
 Headache
 Constipation or diarrhea
Endometriosis – is one of the most common GYN diseases.
 Bits of functioning endometrial tissue are located outside of their normal site, the uterine
cavity.
 Commonly found attached to the ovaries, fallopian tubes, the outer surface of the uterus,
the vagina, and rectum.
 #1 major risk factor for developing endometriosis is family hx in first-degree relative.
 The two most common symptoms are infertility and pelvic pain.
 The aim to therapy is to suppress levels of estrogen and progesterone, which cause the
endometrium to grow.
 Current treatment is based on surgery and ovarian suppressive agents
 Two biggest clinical manifestations are infertility and back pain, followed by chronic
pelvic pain.
 Hallmark finding is the presence of tender nodular masses on the uterosacral ligaments.
 The only definitive DX is made during surgery via laparoscopy.
Infertility – is defined as the inability to conceive a child after 1 year of regular sexual
intercourse (unprotected)
Secondary infertility is the inability to conceive after previous pregnancy.
Infertility is also defined as inability to conceive after 6 months after the age 35 yrs old
 Female causes – anovulation, tubal damage, endometriosis, and ovarian failure.
 Male causes – low or absent numbers of motile sperm, unexplained infertility. Normal
males have more than 20 million sperm with greater than 50% motility.
Infertility testing usually start with men (sperm count) – he should abstain from sexual activity
for 24-48 hours before giving sample. It must be delivered to lab within 1-2 hours.
Assessing female – assessment of ovarian function, ovulation predictor kits, Urinary LH levels.
Clomiphene citrate challenge test, assessment of pelvic organs.
Box 4.5 outline of contraceptive methods
Reversible methods
 Behavioral – abstinence, fertility awareness-based methods, withdrawal (coitus
interruptus), Lactational amenorrhea method LAM
 Barrier – condom (male or female), diaphragm, cervical cup, sponge.
 Hormonal – Ocs, injectable contraceptives, transdermal patch, vaginal ring, IUC,
Implantable device, emergency contraceptive.

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Permanent method –
 Tubal ligation (female)
 Vasectomy (men)
Read table 4.4 pg 136-139
Sexual abstinence – not having vaginal or annual intercourse.
Fertility awareness methods (FAM)– refers to any natural contraceptive method that does not
require hormones, pharmaceutical compounds, physical barriers, or surgery to prevent
pregnancy.
 Cervical mucus ovulation method – is used to assess the character of the cervical mucus.
During ovulation = is becomes more abundant, clear, slippery, and smooth. It can be
stretched between two fingers.
 Basal body temperature (BBT) – refers to the lowest temp reached on awakening
 Symptothermal method – relies on combination of techniques that recognize ovulation,
including BBT, cervical mucus changes, symptoms of ovulation (increased libido, lower
abdominal pain)
 Standard days method- prevent pregnancy by avoid sex on days 8-19 of their cycles.
Barrier methods
 Condoms – made for male and female
 Diaphragm – soft latex dome surrounded by metal spring, used in conjunction with
spermicidal jelly or cream. (must be placed 4 hrs before and left in 6 hours after.) New
one size fits all method also contains HIV microbicide dapivirne.
 Cervical cap – is smaller than the diaphragm and covers only the cervix; its held in place
by suction.
 Contraceptive sponge – No STI protection. Is a nonhormonal, non-prescription device
that includes both a barrier and a spermicide. Should not be left in for more than 30
hours, could cause TSS
 Oral contraceptives – work primarily by suppressing ovulation by adding estrogen and
progesterone to a womens body.
Box 4.6 early signs of complications for users of OCs
A= abdominal pain may indicate liver or gallbladder problems.
C= chest pain or shortness of breath may indicate pulmonary embolism.
H= headaches may indicate hypertension or impending stroke.
E= eye problems may indicate hypertension or an attack
S= severe leg pain may indicate a thromboembolic event.

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Injectable contraceptive – depo-provera; a single injection of 150 mg / 1ml into the buttocks
 Common side effects = spotting, weight gain, depression
Transdermal patches – Ortho Evra ; placed on the lower abdomen, upper arms, buttocks or torso.
 Applies weekly for 3 weeks, followed by a patch-free week (bleeding)
 Patient cant weight more than 198lbs
Vaginal rings – Contains both estrogen and progesterone.
Implantable contraceptives – subdermal time-release method that delivers synthetic progestin.
 3 years continuous highly effective contraception
Intrauterine contraceptives – also known as IUD, IUC.
 Merina- 5-year protection, some have used it for 7 years
 Skyla – 3-year protection
 Para-Guard – 10- year protection
 String checks every month
Box 4.7 Warnings for intrauterine system users of potential complications
 P = period late, pregnancy, abnormal spotting or bleeding.
 A = abdominal pain, pain with intercourse.
 I = Infection exposure, abnormal vaginal discharge
 N = Not feeling well, fever, chills, headaches
 S= Sting length shorter, or missing.
Emergency Contraceptive (EC) – reduces the risk of pregnancy after unprotected intercourse or
contraceptive failure such as condom breakage.
 It is used within 72 hour
 The sooner it is taken the more effective it is.
 ECs do not offer protection against STIs
 Should not be used in place of regular birth control
 Contraindicated during pregnancy.
Sterilization – is a permanent, safe, and highly effective method of contraception.
 Tubal ligation (female) – preformed postpartum, after an abortion, or as an interval
procedure unrelated to pregnancy.
 Vasectomy (male) – is accomplished with surgical procedure. Is performed under local
anesthesia in a urologist office. Small incision is made into the scrotum and cutting the
vas deferens, which carries sperm from the testes to the penis.
Abortion – is defined as the expulsion of an embryo or fetus before it is viable.

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 Surgical abortion is the most common procedure. Done via a Vacuum aspiration or
dilation and evacuation (D&C) method. The entire procedure last about 10 mins.
 Medical Abortion is achieved through administration of medication either vaginally or
orally.
 Methotrexate (an antineoplastic agent)
 Misoprostol (prostaglandin agent Cytotec)
 Mifespristone (a progesterone antagonist)
Menopausal Transition – refers to the transition from women’s reproductive phase of her life to
her final menstrual period.
 Perimenopause- the end of menstruation and childbearing compacity
 1 year without menstrual period at age 51.4 years old
 Ovaries begin to fail, producing irregular and missed periods and occasional hot flashes.
Body systems affected during menopause.
 Brain – HOT FLASHES, disturbed sleep, mood and memory problems.
 Cardiovascular – Lower levels of HDL and increased risk for CVD
 Skeletal – rapid loss of bone density that increases the risk OSTEOPROSIS
 Breast- replacement of duct and glandular tissue by fat
 Genitourinary- less absorption of calcium from food, increased the risk for fractures.
 Integumentary- dry, thin skin and decreased COLLAGEN levels.
 Body shape – more abdominal fat, waist size that swells relative to hips.
Therapeutic Management – Hormone therapy, managing symptoms.
Box 4.9 common symptoms of menopause
 Hot flashes – usually start at the head and neck.
 Dryness in eyes the vagina
 Personality changes
 Anxiety // depression
 Loss of libido
 Weight gain // water retention
 Night sweats
 Atrophic changes – loss of elasticity of vaginal tissues
 Fatigue
 Poor self-esteem
 Insomnia
 Heart palpitations
Dyspareunia – difficult or painful sexual intercourse, loss of lubrication with intercourse, vaginal
dryness, and decrease in sexual desire.

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Osteoporosis – is the state of diminished bone density; characterized by low bone mass and
microarchitectural deterioration of bone tissue with consequent increase in bone fragility and
susceptibility.
 Bone loss begins in third or fourth decade of womens life
 Hip fractures is the most devastating factures of secondary osteoporosis.
 Prevent is key!!
Medications that can help in preventing and managing osteoporosis
 HT (Premarin)
 SERMS (raloxifene)
 Calcium and Vit D supplements
 Estrogen agonist / antagonist
 Bisphosphonates
 Parathyroid hormone
 Calcitonin.
CVD – remains the number one killer of women
 Increased rates of obesity, sedentary life style, DM, and high cholesterol
 Prevention is key.
 Two major risk factors = hypertension, and hyperlipidemia
Atypical cardiovascular symptoms in women.
 A- Angina (chest pain)
 B – Breathlessness
 C- Chronic fatigue
 D- Dizziness
 E – edema
 F – fluttering of the heart
 G- Gastric upset
 H- heavy pain in back and in shoulders.
Chapter 5
Sexually transmitted infections (STIs) are bacterial, viral, and parasitic infections of the
reproductive tract.
 STIs are biologically sexist presenting greater risk for women than men.
 Individuals aged 15-24 years represent almost half of all cases
 Higher risk = African American, American Indian/Alaska native, Hispanic
Box 5.1 CDC classifications of STIs
Infections characterized by VAGINAL DISCHARGE
 Vulvovaginal Candidiasis

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 Trichomoniasis
 Bacterial vaginosis
Infections characterized by CERVICITIS
 Chlamydia
 Gonorrhea
Infections characterized by GENITAL ULCERS
 Genital herpes simplex
 Syphilis
Pelvic inflammatory Disease (PID)
Human immunodeficiency virus (HIV)
Human papillomavirus (HPV)
Vaccine preventable STIs
 Hepatitis A
 Hepatitis B
Ectoparasitic infections
Pediculosis pubis (public lice)
Scabies
Table 5.2 READ sexually transmitted infections common in adolescents pg 178-181
Vaginitis – a generic term that means inflammation and infection of the vagina
 Candida (fungus)
 Trichomonas (protozoa)
 Gardnerella (bacterium)
 Primary prevention begins with changing sexual behaviors that place them at risk.
Teaching guidelines for preventing vaginitis
 Avoid douching to prevent altering vaginal environment
 Use of condoms to avoid spreading it
 Avoid wearing tights, nylon underpants, and tight clothes.
 Wipe from front to back
 Avoid powders, bubble baths, perfumed vaginal sprays
 Wear clean cotton underwear
 Change out of wet bathing suit as soon as possible
 Know signs of vaginitis
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Genital/ vulvovaginal candidiasis (VVC) – is one of the most common causes of vaginal
discharge.
 Also called yeast, monilia, fungal infection
 Not an STI
 Treatment – medications that end in AZOLE. = MiconAZOLE, clotrimAZOLE,
terconAZOLE, fluconAZOLE
 Treatment of choice is fluconazole 150 mg oral tablet // one dose
 If VVC is not treated effectively during pregnancy, the newborn can develop an oral
infection known as THRUSH
 Typical symptoms – pruritis, vaginal discharge (think, white, curd like), vaginal soreness,
vulvar burning.
 Teach preventive measure pg 184. Like shower rather than tub baths, dry underwear in a
hot dryer.
Trichomonas – common vaginal infection; can be obtained from damp/wet surfaces like hot tubs.
However most often it is sexually transmitted.
 Treatment – single 2-g dose of oral metronidazole or tinidazole for both partners
 Signs and symptoms – heavy yellow/ green or gray frothy or bubbly discharge, vaginal
itching, cervix may bleed on contact (friable cervix), dysuria, petechia on the cervix.
 Patient should avoid sexual activity until both partners have been treated.
 Avoid drinking alcohol during treatment
Bacterial vaginosis BV – third common infection of the vagina is caused by gram-negative
bacillus G. vaginalis/
 It is sexually associated
 Causes alterations in the vaginal flora
 Treatment is usually metronidazole (oral or gel) or clindamycin cream.
 Primary symptoms are thin, white homogenous vaginal discharge (stale fish odor)
 Dx- three of the four must be present
 Thin, white vaginal discharge
 Vaginal ph 4.5
 Positive whiff test
 The presence of clue cells on wet mount exam
Cervicitis – catch all term that implies the presence of inflammation or infection of the cervix.
Chlamydia – most common bacterial STI
 Asymptomatic infection is common among both men and women
 Men primary develop urethritis
 Women are linked with cervicitis, acute urethral syndrome, salpingitis, ectopic
pregnancy, PID, and infertility.
 Caused by chlamydia trachomatis bacterium
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 Treatment – Doxycycline 100 mg orally bid for 7 days, or azithromycin 1 g orally in a

single dose.
 Because often chlamydia and gonorrhea go hand in hand a combination treatment method
is recommended (ceftriaxone with doxycycline.
 Symptoms – mucopurulent vaginal discharge, urethritis, bartholinitis, endometritis,
salpingitis, dysfunctional uterine bleeding.
Gonorrhea – second most common STI
 Increases risk of PID, infertility, ectopic pregnancy, and HIV
 It is almost always transmitted via sexual activity.
 Treatment – dual therapy two drugs. Azithromycin 1 g orally single dose, ceftriaxone
250 mg IM single dose.
 If gonorrhea remains untreated, it can enter the blood stream and produce a disseminated
gonococcal infection.
Genital Herpes Simplex – life long viral infection that has the potential for transmission
throughout the lifespan.
 Is transmitted by contact of mucous membranes or breaks in the skin with visible or
nonvisible lesions
 Treatment – no cure exist, but antivirals reduce or suppress symptoms, shedding, and
recurrent episodes.
 Drug of choice is acyclovir 400 mg orally TID for 7-10 days. (the cheaper medication)
 Primary episodes – are usually the most severe with a prolonged period of viral shedding.
Painful vesicular lesions, fever, mucopurulent discharge, superinfection, chills, malaise,
dysuria, headache, inguinal tenderness.
 Recurrent infection episodes are usually much milder and shorter in duration than the
primary one. Tingling, itching, pain, unilateral genital lesions.
Syphilis – chronic multistage, curable bacterial infection.
 PCN G is the first line drug for all stages of syphilis.
 Benzathine Penicillin G administered via IM or IV
 Women should be reevaluated at 6-12 months after treatment
 Primary syphilis is characterized by chancre (painless ulcers) at the site of bacterial entry.
Usually disappear in 1-6 weeks, painless bilateral adenopathy are present during highly
infectious period.
 Secondary syphilis – if primary is left untreated it will progress. Appears 2-6 months
after initial exposure and is manifested by flu-like symptoms, maculopapular rash on
trunk, palms, and soles. (fever, pharyngitis, weight loss, fatigue.)
 The secondary stage last about 2 years
 Latency – once the secondary stage subsides the latency period begins. Characterized by
the absence of any clinical manifestations.
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 Tertiary syphilis- if latency is left untreated will turn into tertiary. It can last as long as 20
years. Life threatening heart disease and neurological disease that slowly destroys -the
heart, eyes, brain, and CNS.
 DX- VDRL and RPR
Teaching guidelines caring for genital ulcers
 Abstain from intercourse during the prodromal period and when lesions are present.
 Wash hands with soap and water after touching lesions
 Avoid extremes of temperature such as ice packs or hot pads as well as applications of
steroid creams, sprays, or gels.
 Use condoms with all new uninfected partners.
Pelvic Inflammatory disease (PID) – infection induced inflammation of the female reproductive
tract.
 It may involve the uterine lining (endometritis) the connective tissue adjected to the
uterus (parametritis), the fallopian tubes (salpingitis), or serous membrane that lines part
of the abdominal cavity.
 Treatment – broad-spectrum antibiotic therapy. Cephalosporin with doxycycline 100 mg
bid for 14 days. Maintain hydration
Minimal criteria (all must be present)
 Lower abdominal tenderness
 Adnexal tenderness
 Cervical motion tenderness
Teaching guidelines – preventing PID
 Advise sexually active girls and women to insist their partner use condoms
 Discourage routine vaginal douching, as this may lead to bacterial overgrowth
 Encourage regular STI screening
 Emphasize the importance of having each sexual partner receive antibiotic treatment.
Vaccine preventable STIs
Human papillomavirus – most common viral infection
 Genital warts or condylomata are caused by HPV
 HPV is prevalent in young women between the ages 20-24 years old
 Most HPV infections are asymptomatic, unrecognized or subclinical.
 Genital warts are usually caused by HPV types 6 or 11
 Treatment – no cure so prevention is key (Gardasil, cervarix are vaccines to prevent
HPV)
 The goal for treating genital warts is to remove the warts (cryotherapy)
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Hepatitis A
 Is spread via the GI tract; it can be acquired by drinking polluted water, eating uncooked
shellfish
Hepatitis B
 Is spread via saliva, blood, serum, semen, menstrual blood, and vaginal secreation.
 Incubation period from exposure to onset of symptoms 6 weeks to 6 months
 Hep B vaccine is strongly advised and given to most infants/newborn prior to discharge
from the hospital
Has the highest death rate of any STI except HIV
Unlike other STIs HBV, HAV are preventable through immunization.
Symptoms of Hep A and Hep B – flu-like symptoms with malaise, skin rashes, fatigue, anorexia,
nausea, pruritus, fever, and upper right quadrant pain.
Ectoparasitic infection – are common causes of skin rash and pruritus throughout the world.
These infections include – scabies and pubic lice.
Scabies is an intensely pruritic dermatitis caused by a mite.
 The female mite burrows under the skin and deposits eggs, which hatch.
 The lesions start as small papule that reddens, erodes and sometimes crusts.
 Treatment is permethrin 1% cream rinse and pyrethrin with piperonylbutoxide
Human immunodeficiency Virus HIV- is transmitted by intimate sexual contact, by sharing
needles, and from mother to fetus during pregnancy.
 Acute primary infection – occurs 2-6 weeks after exposure; symptoms = include fever,
pharyngitis, rash, and myaligia.
 After exposure, there is a period of 3-12 months before seroconversion
 Dx testing – RNA and rapid HIV test
 TX is done via HAART therapy
HIV during pregnancy and childbirth
 Mother receives ART during pregnancy
 HIV can spread to the infant through breastfeeding
 Mothers have to avoid breastfeeding.
Box 5.3 Nursing strategies to prevent the spread of STIS
 Provide basic information about STI transmission
 Outline safer sexual behaviors
 Screen asymptomatic persons with STIs
 Counsel and treat sexual partners of persons with STIs
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 Promote use of barrier methods (condoms, diaphragms)

Chapter 6
Benign breast disorder – is any noncancerous breast abnormality.
 Can cause pain and discomfort
 Most common disorders include fibrocystic changes of the breast, fibroadenomas,
mastitis.
Fibrocystic breast changes – also known as benign breast disease (BBD) caused by an over
growth of fibrous tissues in the connective tissue.
 Nipple discharge = may or may not be present.
 Site – bilateral; upper out quadrant
 Characteristics / age of the client – round, smooth, several lesions. Cyclic, palpable, (age
30-50 years)
 Tenderness – present
 Dx & treatment – aspiration and bx; limit caffeine; ibuprofen; supportive bra.
 In severe cases drugs including bromocriptine, tamoxifen or danazol can be used to
reduce influence of estrogen.
Teaching guidelines 6.1 Relieving symptoms of fibrocystic breast changes.
 Wear supportive bra
 Take oral contraceptives
 Eat a low fat diet rich in fruits and veggies
 Apply heat to the breast to reduce pain
 Take diuretics
 Reduce salt intake to reduce fluid retention.
 Take OTC meds (aspirin, ibuprofen) to reduce inflammation.
 Use thiamine and vit E therapy
 Take prescribe meds (bromicriptine, tamoxifen, danazol)
 Avoid caffeinated drinks (coffee, tea, soda)
Fibroadenomas – common solid breast tumors. They are considered hyperplastic breast lesions
associated with an aberration of normal development and involuation rather than a neoplasm.
 Nipple discharge – none present
 Site – unilateral; nipple area or upper outer quadrant
 Characteristics / age of the client – round firm, moveable palpable, rubbery, well
delineated, single lesion. (age 15-30 years old)
 Tenderness – none present
 Dx & treatment – mammogram, ultrasound or both; “watchful waiting” Aspiration and
BX, surgical excision.
 These masses are frequently larger than 5 cm and occur most often in pregnant or
lactating women.
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Mastitis – is an infection or inflammation of the connective tissue in the breast that occurs
primarily in lactating or engorged women.
 Lactational causes – staphylococcus aureus, haemophilus influenza, streptococcus
species; usually occurs in the first 2-3 weeks of lactation.
 Nonlactational mastitis – can be caused can be caused by duct ectasia which occurs when
the milk ducts become congested with secretions or debris.
 Periareolar infection – consist of active inflammation around nondilated subareolar breast
ducts. (periductal mastitis)
 Present symptoms – greenish nipple discharge, nipple retraction, and noncyclical
pain.
 Tx – effective milk removal, pain medications, antibiotic therapy. (usually Penicillinase-
resistant PCN or cephalosporin). Warm compresses to the inflamed area of the breast,
continued breastfeeding, and Tylenol for pain and fever.
Teaching guidelines 6.2 Caring for Mastitis
 Take meds as prescribed
 Continue to breastfeed
 Begin feeding on most affected breast to allow it to be emptied first
 Massage the breast before and during the breast feeding to encourage milk extraction.
 Wear supportive bra 24 hours a day
 Increase fluid intake (stay hydrated)
 Gentle massage toweard nipple several times daily
 Practice good hand hygiene
 Apply warm compresses
 Get adequate rest and nutrition
Malignant breast disorders.
Breast cancer is a neoplastic disease in which normal body cells are transformed into malignant
ones.
 Is the most common cancer in women and second leading cause of cancer deaths (lung
cancer is first)
 The most common clinical manifestations of male breast cancer is painless, firm,
subareolar breast mass.
 Noninvasive, or in situ, breast cancer are those that have not externed beyond their duct,
lobule, or point of origin into the surrounding breast tissue.
 Invasive (infiltrating) breast cancers have extended into surrounding breast tissue with
the potential to metastasize.
 Breast cancer metastasize widely and to almost all organs of the body. Primarily to the
bone, lungs, lymph nodes, liver, and brain. The first sites are usually local or regional
involving the chest wall, or axillary supraclavicular lymph nodes or bones.
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Invasive ductal carcinoma – is the most common breast cancer. A malignant tumor that occurs in
the epithelial tissue.
 It tends to infiltrate and give rose to metastases
 It spreads rapidly to axillary and other lymph nodes.
Invasive lobular carcinoma – originate in the terminal lobular units of breast ducts.
 Usually in women aged 40-50 years
 It presents as an area of ill-defined thickening rather than a palpable mass.
 Frequently located in the upper outer quadrant of the breast
Staging of breast cancer – breast cancer is classified into three stages based on:
 Tumor size
 Extent of lymph node involvement
 Evidence of metastasis
The purpose of tumor staging are to determine the probability that the tumor has metastasized, to
decide on appropriate course of therapy, and to assess the clients prognosis.
 Stage 0- in situ, early type of breast cancer.
 Stage I – localized tumor <1 inch in diameter.
 Stage II – tumor 1-2 inc in diameter; spread to other axillary lymph nodes.
 Stage III- tumor 2 inch or larger; spread to other lymph nodes and tissues
 Stage IV – cancer has metastasized to other body organs.
Estimated risk of breast cancer at specific ages
 Ages 30-39 – 1 out of 233
 Ages 40-49 – 1 out of 69
 Ages 50-59 – 1 out of 42
 Ages 60-69 – 1 out of 29
Nonmodifiable risk factors
 Gender (female)
 Aging (>50)
 Genetic mutations (BRCA 1 and BRCA 2 genes)
 Personal hx of ovarian or colon cancer
 Increased breast density
 Family hx of breast cancer
 Early menarche <12 years old
 Late menopause >55 year old
 Exposure to chest radiation
Modifiable risk factors
 Not having children or having children >30 years old
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 Postmenopausal use of estrogens and progestins

 Failing to breast-feed for up to a year
 Alcohol consumption
 Smoking
 Obesity
 Sedentary lifestyle.
Screening – BSE, CBE, and mammography.
Teaching guidelines 6.3 Preparing for a screening mammogram
 Schedule the procedure just after menses, when breast are less tender
 Do not use deodorant or powder on the day of procedure.
 Acetaminophen can relieve any discomfort
 Remove all jewelry
Magnetic resonance mammography – relatively new procedure that might allow for earlier
detection because it can detect smaller lesions and provide finer detail.
 MRM is used as a complement to mammography and CBE because it is expensive.
Fine-needle aspiration BX or core BX
 Fine-needle is done to identify solid tumor, cyst, or malignancy; a small 23-27 g needle is
connected to a 10 mL syringe and inserted into the breast mass.
 Core needle BX is much life fine-needle Bx except that a larger needles is used to
withdraw a small cylinders or cores of tissue.
Stereotactic needle guided bx- tool used to target and identify mammographically detected
nonpalpable lesions in the breast. Takes place in specially equipped and takes about an hour.
Sentinel Lymph node bx – The more lymph nodes involved the more aggressive the cancer, the
more powerful chemotherapy will have to be.
 The clinician can determine whether breast cancer has spread to the axillary lymph nodes
without have do a traditional axillary lymph node dissection.
 The first lymph node is called the sentinel lymph node.
 A radioactive blue dye is injected 2 hours before the bx
Therapeutic management –
 Local treatment – are surgery, radiation therapy,
 Systemic treatment – chemotherapy, hormonal therapy and immunotherapy.
Surgical options –
 Breast conserving surgery – lumpectomy with radiation or mastectomy with our without
reconstruction.
 Mastectomy – is the removal of all breast tissue, the nipple, and the areola. This
procedure is used for large tumors or multiple tumors.
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Adjunctive therapy – is supportive or additional therapy recommend after surgery.

 Radiation therapy – uses high energy rays to destroy cancer cells that might have been
left behind in the breast, chest wall, or underarm. Usually serial radiation doses are given
5 days a week to the tumor site.
 Side effects include inflammation, local edema, anorexia, swelling, heaviness in
the breast; sunburn like rash
 Chemotherapy – refers to the use of drugs that are toxic to all cells and interfere with a
cells ability to reproduce.
 Chemo is indicated for with tumors larger than 1 cm, positive lymph nodes, or
aggressive cancer.
 Most common chemo drugs are alkylating agents, anthracyclines, antimetabolites
 The most serious side effect is bone marrow suppression.
 Hormonal therapy – the objective of endocrine therapy is to block or counter the effect of
estrogen.
 They include selective estrogen receptor modulators SERMs, estrogen receptor
downgraders, luteinizing hormones.
 Side effects include hot flashes, bone pain, bone thinning, insomnia, weight gain,
depression, fatigue, nausea, cough, dyspnea, and headache.
 Immunotherapy – attempts to simulate the body’s natural defenses to recognize and
attack cancer cells.
Concept mastery alert – tamoxifen versus trastuzumab is breast cancer treatment; tamoxifen is a
selective estrogen receptor modulator used to prevent further spread of breast cancer in women
with ER-positive breast cancer. Trastuzumab is a monoclonal antibody used in the treatment of
breast cancer and is considered immunotherapy.
Box 6.1 clinical breast examination by health care provider.
Purpose: to assess breast for abnormal findings.
1. Inspect the breast for size, symmetry, and skin texture and color. It is common for the left
breast to be slightly larger than the right. Inspect the nipples and areola. Ask the client to
sit at the edge of the exam table, with her arms resting at her side.
2. Inspect the breast for masses, retraction, dimpling, or ecchymosis.
3. She then raises her arms over her head so the axillae can also be inspected
4. The client then stands, places her hands on her hips and leans forward.
5. Palpate the breast using the pads of your first three fingers and make a rotary motion.
Assist the client into a supine position with her arms above her head. Place a pillow or
towel under the clients head to help spread the breast.
 Three patterns can be used – spiral, pie shaped wedges, vertical strip.
Table 6.5 characteristics of benign versus malignant breast masses
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Benign breast masses are described as:

 Frequently painful
 Firm, rubbery mass
 Bilateral masses
 Include nipple discharge
 Regular margins (clearly delineated)
 No skin dimpling
 No nipple retraction
 Mobile, not affixed to the chest wall
 No bloody discharge.
Malignant breast masses are described as:
 Hard to palpation
 Painless
 Irregularly shaped (poorly delineated)
 Immobile, fixed to the chest wall
 Skin dimpling
 Nipple retraction
 Unilateral mass
 Blood, serosanguineous, or serous nipple discharge
 Spontaneous nipple discharge.
Breast cancer screening – the three components of early detection are BSE, CBE, and
mammography.
The most commonly encountered benign breast disorders in women include fibrocystic breasts,
fibroadenomas, and mastitis.
Fibroadenomas are common benign solid breast tumors that can be stimulated by external
estrogen, progesterone, lactation and pregnancy.
Mastitis is an infection of the connective tissue in the breast that occurs primarily in lactating or
engorged women, it is divided into lactational or nonlactational types.
 Management of both types involves the use of oral antibiotics (usually penicillinase-
resistant penicillin or cephalosporin) and acetaminophen for pain and fever.
Breast cancer metastasized widely and to almost all organs of the body, but primarily to the
bone, lungs, lymph nodes, liver, and brain.
Chapter 7
Pelvic organ prolapse – refers to the abnormal descent or herniation of the pelvic organs from
their original attachment sites to their normal position in the pelvis
Types of pelvic organ prolapse.
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 Cystocele – occurs when the posterior bladder wall protrudes downward through the
anterior vaginal wall.
 Rectocele – occurs when the rectum sags and pushes against or into the posterior vaginal
wall.
 Enterocele – occurs when the small intestine bulges through the posterior vaginal wall
(especially common when straining)
 Uterine prolapse – occurs when the uterus descends through the pelvic floor and into the
vaginal canal.
 Stage 0 – no descent of pelvic structure during straining.
 Stage 1 – the prolapsed descending organ is >1 cm above the hymenal ring
 Stage 2 – the prolapsed organ extends ~1 below the hymenal rings ‘
 Stage 3 – the prolapsed organ extends 2-3 cm below the hymenal ring
 Stage 4 – the vagina is completely everted, or prolapsed organ is >3 cm below the
hymenal ring.
Therapeutic management – conservative measures such as PFMEs or Kegel exercise
supplemented by lifestyle interventions such as weight loss, avoidance of straining, reduce heavy
lifting, treatment of chronic cough and constipation.
Treatment options – estrogen therapy, dietary and lifestyle modifications, use of a pessary, and
surgery.
TAKE NOTE !- before hormone therapy is considered a though medical hx must be taken to
asses a women’s risk for complications. (endometrial cancer, myocardial infarction, stroke,
breast cancer, pulmonary emboli, and DVT.) because of these risk, estrogens with or without
progestins, should be given at the lowest effective dose and for the shortest duration.
Diet and lifestyle modifications –
 Avoiding constipation, bladder irritants, heavy lifting, high impact exercise, eight loss,
and smoking cessation.
Pessaries – are synthetic devices inserted in the vagina to provide support to the bladder and
other pelvic organs as a corrective measure for UI and/or POP.
 Most commonly used; is a firm ring that presses against the wall of the vagina and
urethra to help decrease leakage and support a prolapsed vagina or uterus.
 Indications for use- uterine prolapse, cystocele.
 More common among elderly women and for clients whom surgery is contraindicated;
younger women with prolapse who wish to have additional children.
 Most common side effect -vaginal discharge, urinary tract infections, vaginitis, and odor.
 Odors can be reduced by douching with dilute vinegar or hydrogen peroxides
 Remove pessary twice weekly and clean with soap and water
 Use lubricant for reinsertion
 Have regular follow-up every 6-12 months
Surgical interventions –
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 Anterior or posterior colporrhaphy (to repair cystocele or rectocele)

 Vaginal hysterectomy (uterine prolapse) * treatment of choice
Symptoms common to all types of prolapse are a feeling of dragging, a lump in the vagina, or
something “coming down.” Vaginal bulging or pelvic pressure, bladder, bowel, or pelvic
symptoms.
Box 7.1 symptoms associated with pelvic organ prolapse.
Urinary symptoms –
 Stress incontinence
 Frequency (diurnal and nocturnal)
 Urgency and urge incontinence
 Hesitancy
 Poor or prolonged stream
 Feeling of incomplete emptying
Bowel symptoms –
 Difficulty with defecation
 Incontinence of flatus or liquid or solid stool
 Urgency of defecation
 Feeling of incomplete evacuation
 Rectal protrusion or prolapse after defecation
Sexual symptoms –
 Inability to have frequent intercourse
 Dyspareunia (pain during sex)
 Lack of satisfaction or orgasm
 Incontinence during sexual activity
Other local symptoms-
 Pressure or heaviness in the vagina
 Pain in the vagina or perineum
 Low back pain after long periods of standing
 Palpable bulge in the vaginal vault
 Difficulty walking due to a protrusion from the vagina
 Difficulty inserting or keeping in a tampon
 Vaginal cervical mucosa hypertrophy, excoriation, ulceration, and bleeding.
 Abdominal pressure or pain.
Urinary incontinence- involuntary loss of urine that represents a hygienic or social problem to
the individual.
 Incontinence is preventable, treatable, and often curable.
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Urge incontinence – precipitous loss of urine, preceded by a strong urge to void, with increased
bladder pressure and detrusor contraction.
 Causes might be neurologic, idiopathic, or infections
 Signs and symptoms – urgency, frequency, nocturia, and large amount of urine loss.
 Effective treatments – bladder training (voiding intervals every 3-5 hrs), PFME, pessary
ring, Pharmacotherapy (anticholinergic agents – oxybutynin or Detrol)
 Side effects to anticholinergic agents – dry mouth, blurred vision, constipation, nausea,
dizziness, and headaches.
Stress incontinence – accidental leakage of urine that occurs with increased pressure on the
bladder from coughing, sneezing, laughing, or physical exertion.
 Develops commonly in women in their 40-50s, usually as the result of weakened muscles
and ligaments in the pelvis following childbirth.
 Involuntary loss of a small amount of urine in response to physical activity that raises
intra-abdominal pressure.
 Effective treatments – weight loss if needed, avoidance of constipation, smoking
cessation, PFMEs, pessaries, weighted vaginal cones.
 Medications such as duloxetine (Cymbalta, yentreve)
Mixed incontinence involves both UI and Stress incontinence.
READ!! Teaching guidelines 7.2 managing urinary incontinence pg 254
TAKE NOTE! – simple diet and lifestyle alterations, combined with a proper pelvic floor muscle
strengthening program, can often produce significant improvements for women of all ages.
Benign growths-
Polyps – are small usually benign growths. Malignancy is more common in perimenopausal and
postmenopausal women.
 They are the most common in multiparous women
 Most common in the cervix and in the uterus.
 Cervical polyps often appear after menarche.
 Endocervical polyps are more common than cervical polyps.
 Treatment – usually consist of removing via small forceps done on an outpatient basis,
removal during hysteroscopy, or D&C.
 Cervical bx usually reveals mildly atypical cells and signs of infection.
 Most endometrial bx are cherry red
 Most cervical bx are grayish-white.
 Signs and symptoms –(they are usually asymptomatic) however can produce; abnormal
vaginal bleeding (after intercourse, or douching, between menses) or discharge. ** the
most common is metrorrhagia (irregular acyclic uterine bleeding)
Uterine fibroids – also known as myomasor leiomyomas, are benign tumors composed of smooth
muscle and fibrous connective tissue in the uterus.
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 Usually grow slower responding to present estrogen levels and their cells do not break
away and invade other parts of the body.
 Fibroids are estrogen-dependent and thus grow rapidly during the childbearing years.
 Fibroids are the most common indication for hysterectomy
 Subserosol fibroids: lie underneath the outermost peritoneal layer of the uterus and grow
outside the uterus. (they are attached to the uterus by stalk or peduncle)
 Intramural fibroids: grow within the wall of the uterus and *the most common type*
 Submucosal fibroids: grow from immediately below the inner uterine surface
(endometrium) into the uterine cavity.
 Symptoms – heavy or painful menses, feeling “full” in the lower pelvis, urinating
frequently, pain during sexual intercourse, lower back pain, infertility.
 Medical management – goal are to reduce symptoms and /or reduce tumor size.
 Birth control pills to control heavy menses
 GnRH such as leuprolide (Lupron), nafarelin (syneral) or goserelin (zoladex)
which stop ovulation and the production of estrogen, or low dose mifepristone, a
progestin antagonist. (side effects – vaginal dryness, bone loss, headaches, hot
flashes, mood changes)
Surgical management – for large fibroids or severe menorrhagia, surgery is the preferred method.
Table 7.1 summary of treatment options for uterine fibroids
 Hormones- noninvasive; reduces size of fibroids; symptoms improvement; serious side
effect with long term use; fibroids regrow when meds stop.
 Uterine Artery embolization – minimally invasive; dramatic decrease in symptoms;
future fertility possible; procedure frequently painful; requires radiation and contrast dye;
permanently implanted martial; possible negative fertility impact.
 Myomectomy – noninvasive, reduces of fibroids, symptom improvement. Requires
general anesthesia; new growths can occur.
 Hysterectomy – complete removal of fibroids; immediate symptoms relief; requires
general anesthesia, major surgery with associated risk, fertility not preserved. (top three
conditions are fibroids, endometriosis, uterine prolapse)
 Laser surgery – can be done as an outpatient procedure to destroy small fibroid;
vaporization process can cause scarring and adhesions, affecting future fertility.
Box 7.2 nursing interventions for women undergoing a hysterectomy –
Preoperative care –
 Instruct the client and her family about the procedure and aftercare.
 Provide interventions to reduce anxiety and fear. Prepare women so she knows what to
expect. Explain postoperative pain management procedures.
 Teach turning, deep breathing, and coughing before surgery to prevent post-op atelectasis
and respiratory complications.
 Complete all pre-op orders in a timely manner.
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Postoperative care –
 Provide comfort measures
 Administer analgesics promptly (PCA pump)
 Administer antiemetics to control nausea and vomiting
 Change clients position frequently and use pillows to promote comfort and pain
management.
 Assess the incision, the dressing, and vaginal bleeding.
 Monitor elimination and provide fluids and fiber to prevent constipation.
 Encourage ambulation and active range of motion.
 Monitor vital signs
Discharge planning –
 Advise client to reduce her activity level to avoid fatigue, which might inhibit healing.
 Advise client on the need for pelvic rest (nothing in the vagina 6 weeks)
 Avoid heavy lifting or straining for 6 weeks.
 Teach client signs and symptoms of infection
 Advise women to take showers instead of tub baths to prevent infection.
 Encourage client to eat healthy, increase fluid intake to prevent dehydration and fluid and
electrolyte balance.
 Keep follow up appointments
 Provide community resources.
Genital fistulas – abnormal openings between a genital tract organ and another organ such as the
urinary tract or the GI tract.
 A fistula can result from gland abscesses, radiation, or malignancy, nut the majority of
fistulas occur worldwide to OB trauma and female genital cutting.
 Common types of fistulas include:
 Vesicovaginal – communication between the bladder and genital tract
 Urethrovaginal – communication between the urethra and the vagina
 Rectovaginal – communication between the rectum or sigmoid colon and the
vagina.
 The direct consequence of this damage includes UI and fecal incontinence if the rectum
involved.
 Small fistula usually heal without treatment, but large fistula often require surgery repair.
Bartholin cyst – is a swollen, fluid-filled, sac-like structure that results when on of the ducts of
the Bartholin gland becomes blocked.
 Bartholin glands are two mucus-secreting glandular structures with duct opening
bilaterally at the base of the labia minora near the opening of the vagina that provide
lubrication during sex.
 Most common cystic growths in the vulva
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 Small asymptomatic cyst do not require treatment. Sitz baths along with analgesics are
used to reduce discomfort, antibiotics if infected.
 Other treatment options beyond I&D include the placement of a Word catheter or small
loop or plastic tubing secured in place to prevent closure and allow drainage. (usually
removed in 3 weeks)
Ovarian Cyst – fluid-filled sac that forms on the ovary
 Cyst usually discovered during USN or routine pelvic exam.
 Most common benign = follicular cyst, corpus luteum (lutein), theca lutein cyst and
polycystic ovarian syndrome (PCOS)
Follicular cysts – commonly found in the ovaries of prepubertal girls and women of reproductive
age, and in most cases have no clinical significance.
 Seldom grow larger than 5 cm
 Rare after menopause
Corpus Luteum (lutein) cyst – forms when the corpus luteum becomes cystic or hemorrhagic and
fails to degenerate after 14 days
 Typically these cysts appear after ovulation and resolve without intervention
Theca Lutein Cysts – prolonged abnormally high levels of HCG stimulate the development of
theca cyst.
Polycystic ovary syndrome (PCOS) – is the most common endocrine condition in women of
reproductive age
 Presence of multiple inactive follicle cysts within the ovary that interfere with ovarian
function.
 Is associated with obesity, hyperinsulinemia, elevated luteinizing hormone levels, cyst
formation, infertility, metabolic syndrome.
 PCOS is the most cause of medically treatable infertility and is responsible for 70% of
cases of anovulatory subfertility.
 Oral contraceptives, antidiabetic agents, and statins are some of the common therapies
used. Weight loss and surgery may also be beneficial as nondrug options.
 Common signs and symptoms – hirsutism (face, chin, upper lip, areola, lower abdomen,
and perineum), alopecia (frontal region of head), menstrual irregularity, acne.
TAKE NOTE! – careful attention should be given to this condition because affected women are
at increased risk for long-term health problems such as CVD, HTN, dyslipidemia, DM type 2,
infertility, and cancer.
Box 7.3 treatment modalities for PCOS
 Oral contraceptives to treat menstrual irregularities and acne.
 Mechanical hair removal (shaving, waxing, plucking) to treat hirsutism
 Glucophage (metformin) which improves insulin uptake.
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 Ovulation induction agents (clomid) to treat infertility

 Lifestyle changes (weight loss, exercise, balanced low-fat diet)
 Referral to support groups.
Key concepts –
 the four most common types of genital prolapse are cystocele, rectocele, enterocele,
uterine prolapse.
 The three most common types of incontinence are Urge incontinence (over active bladder
caused by detrusor muscle contractions) stress incontinence (inadequate urinary sphincter
function) and mixed incontinence (involves both)
 The most common benign growths of the reproductive tract include cervical,
endocervical, and endometrial polyps; uterine fibroids (leiomyomas) genital fistulas,
Bartholin cyst; and ovarian cyst.
Chapter 8
Cancer is the second leading cause of death for women
Common laboratory and Dx test 8.1
 Clinical breast exam – client may discover lump herself; high-risk hx for breast cancer.
Identifies palpable mass, skin change, inverted nipple, or unresolved rash.
 Mammography – screening modality for breast cancer; detects calcifications, densities,
and nonpalpable cancer lesions.
 Pap smear – cervical cytology screening to dx cervical cancer.
 CA-125 – nonspecific blood test used as a tumor marker. Elevation of marker suggest
malignancy but is not specific to ovarian cancer.
Teaching guidelines 8.1 reducing your risk for cancer
 Do not smoke
 Drink alcohol in moderation (no more than one drink daily)
 Be physically active
 Eat healthy
 Stay current with immunization
 Use a condom with every sexual encounter
 BMI
 Mammogram every 1-2 years starting at age 40
 Pap smear every 1-3 years if sexually active between the ages 21-65
 Blood pressure check
 DM if hypertensive
 Check STI
TAKE NOTE! – when a dx of cancer is made, assessing cultural perspective will help the nurse
provide culturally competent care
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The most frequent malignancies dx during pregnancy are breast cancer, cervical cancer,
hematological malignancies (lymphomas and leukemia) and melanoma.
 Breast cancer is the most common dx
 Ovarian cancer is rare during pregnancy
Ovarian cancer – is malignant neoplastic growth of the ovary
**described as the “over looked disease” or the “silent killer”
 It is the 9th most common cancer among women.
 Most develop in the ovarian epithelium
 Laparoscopy is performed for dx and staging:
 Stage I- is limited to the ovaries.
 Stage II- growth involves one or both ovaries, with pelvic extension.
 Stage III – cancer has spread to the lymph nodes and other organ structures inside
the abdominal cavity.
 Stage IV – the cancer has metastasized to distant sites.
 Surgical intervention remains the mainstay for management of ovarian cancer.
 Total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal
biopsies, omentectomy.
 Chemotherapy is recommended for all stages of ovarian cancers.
 Considered the worst of all GYN malignancies, primarily because they develop slowly
and remain silent without sx until cancer is far advanced.
 The most commonly early sx – abdominal bloating, early satiety, fatigue, vague
abdominal pain, urinary frequency, diarrhea or constipation, malaise, unexplained weight
loss.
TAKE NOTE! – A small ovarian “Cyst” found on ultrasound in an asymptomatic
postmenopausal women should arouse suspicion. Any mass or ovary palpated in postmenopausal
women should be considered cancerous until proven otherwise.
Endometrial Cancer – also known as uterine cancer. Is malignant neoplastic growth of the
uterine lining. It is the 4th most common GYN malignancy.
 It is uncommon before the age 55
 Causes – hx of exposure to unopposed estrogen is the cause of approximately 80% of
women.
 Early tumor growth is characterized by friable and spontaneous bleeding.
 Adenocarcinoma of the endometrium is typically preceded by hyperplasia.
 Carcinoma in situ is found only on the endometrial surface
 Type 1 carcinomas, the most common, begin as endometrial hyperplasia and progress to
carcinoma. If found in early stage treatment results are more favorable.
 Type II carcinomas appear spontaneously, are associated with poorly differentiated cell
type, have poor prognosis.
 If endometrium measure less than 4 mm, the client is at low risk for malignancy.
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 Endometrial bx is an office procedure; the first step in dx of endometrial cancer

Staging the tumor –
 Stage I- the tumor is confined to the corpus uteri.
 Stage II – It has spread to the cervix, but not outside the uterus.
 Stage III- it has spread locally and regionally.
 Stage IV – it has invaded the bladder mucosa, bowel with distant metastases to the lungs,
liver, and bone
**surgery with adjunct therapy is usually the preferred treatment method**
In more advanced cancers, radiation and chemotherapy are used as adjuncts to surgery.
TAKE NOTE!- any episode of bright-red bleeding that occurs after menopause should be
investigated. Abnormal uterine bleeding is rarely the rarely the result of uterine malignancy in
young women, but in the postmenopausal it should be regarded with suspicion.
Teaching guidelines 8.2 preventive and follow-up measure for endometrial cancer
 Schedule regular pelvic exams after age 21
 Visit HCP for early evaluation of any abnormal bleeding after menopause.
 Maintain a low-fat diet throughout life.
 Exercise daily
 Manage weight to discourage hyperestrogenic states, which predispose to endometrial
hyperplasia
 Pregnancy serves as a protective factor by reducing estrogen
 As your dr about the use of combination estrogen and progestin pills
 Be aware of risk factors for endometrial cancer and make needed modifications
 Report any of the follow symptoms immediately
 Bleeding or spotting after sexual intercourse
 Bleeding that lasts longer than a week
 Reappearance of bleeding after 6 months or more of no menses.
Cervical cancer – is cancer of the uterine cervix. It is the third most common genital malignancy
in women.
 Hispanic women are most likely to get cervical cancer, followed by African American,
Asian and Pacific Islanders and white.
 Cervical cancers is one of the most treatable cancers when detected at an early stage.
 Most cases are found in younger than age 50, it rarely develops in women younger than
20.
 HPV infection must be present for cervical cancer to occur.
 Progression from low-grade to high-grade dysplasia usually take an average of 9 years
 Progression from high-grade dysplasia to invasive cancer take up to 2 years.
Cervical dysplasia – disordered growth of abnormal cells.
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Table 8.2 Pap Smear Guidelines

 First pap- cervical cancer screening should begin at age 21. Women under age 21 should
not be tested.
 Ages 21-30 – should have a pap smear every 3 years; HIV testing should not be used in
the age group unless it is needed after an abnormal pap test result.
 Ages 30-65 – should have a pap smear plus an HPV test every 5 years. This is the
preferred approach but having a pap smear alone every 3 years is also okay.
 Age >65 – women who have had regular cervical testing with normal results should not
be tested for cervical cancer. Women with a hx of serious cervical precancer lesions
should continue to test for at least 20 years after the dx, even if it continues after 65 years
old.
 HPV vaccination – women who have received the HPV vaccine should follow the
screening recommendations for her age group.
Box 8.2 treatment options for cervical cancer
 Cryotherapy – destroys abnormal cervical tissue by freezing with liquid nitrogen, freon,
or nitrous oxide. Healing takes up to 6 weeks and the client may experience a profuse,
watery, vaginal discharge for 3-4 weeks
 Cone Bx or conization – removes a cone-shaped section of cervical tissue. The base of
the cone is formed by the ectocervix (outer part of the cervix) and the point or apex of the
cone is from the endocervical canal. The transformation zone is contained within the cone
sample. The cone bx is also treatment and can be used to completely remove any
precancers and very early cancers.
 LEEP (loop electrosurgical excision procedure or LLETZ (large loop excision of the
transformation zone) – the abnormal cervical tissue is removed with a wire that is heated
by an electrical current. For this procedure, a local anesthetic is used. It is preformed in
the HCP office in about 10 minutes. Mild cramping and bleeding may persist for several
weeks after procedure.
 Cold knife cone Bx – a surgical scalpel or a laser is used instead of a heated wire to
remove tissue. This procedure requires general anesthesia and is done in a hospital
setting. After the procedure, cramping and bleeding may persist for a few weeks.
 Laser Therapy – destroys diseased cervical tissue by using a focused beam of high-
energy light to vaporize it (burn it off) after the procedure the women may experience a
watery brown discharge for a few weeks. Very effective in destroying precancers and
prevention of new cancers developing,
 Hysterectomy – removes the uterus and cervix surgically
 Radiation therapy – delivered by internal radium applications to the cervix or external
radiation therapy that includes lymphatics of the pelvis.
 Chemoradiation – weekly cisplatin therapy concurrent with radiation. Investigation of
this therapy is ongoing.
**Clinically the first sign is abnormal vaginal bleeding, usually after sexual intercourse.**
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**Vaginal discomfort, malodorous discharge, and dysuria are other common symptoms.**
TAKE NOTE! – suspect advanced cervical cancer in women with pelvic, back, or leg pain,
weight loss, anorexia, weakness, and fatigue, and fractures.
Review collection of pap smear on pg 287
In a colposcopy, the women is placed in lithotomy position and her cervix is cleansed with acetic
acid solution. Acetic acid makes abnormal cells appear WHITE, which if referred to as
ACETOWHITE
CONCEPT MASTER ALERT- cervical cancer prevention – the key points to remember in
cervical cancer prevention are smoking cessation, limiting alcohol consumption, and
encouraging teens to refrain from early sexual activity
Primary prevention education –
 Identify high risk behaviors in clients and teach them how to reduce such behaviors.
 Take steps to prevent STIs
 Avoid early sexual activity
 Faithfully use barrier methods of contraception.
 Avoid smoking and drinking
 Receive HPV vaccine
 Instruct women on the importance of screening for cervical cancer by having annual pap
smears.
The nurse role in primary prevention of cervical cancer is through education of women regarding
risk factors and preventive vaccines to avoid cervical dysplasia.
Secondary prevention – focuses on reducing or limiting the area of cervical dysplasia
 Pap smear
Tertiary prevention focuses on minimizing disability or the spread of cervical cancer.
 The dx and treatment of confirmed cases of cancer.
 Treatment is typically through surgery, radiotherapy, and frequently chemotherapy.
Teaching guidelines 8.3 – strategies to optimize pap smear results
 Schedule you pap smear appointment about 2 weeks (10-18) days after the first day of
your last menses to increase the chance of getting the best cervical cells without menses.
 Refrain from intercourse for 48 hours before the test because additional matter such as
sperm can obscure the specimen
 Do not douche within 48 hours before the test to prevent washing away cervical cells that
might be abnormal.
 Do not use tampons birth control foams, jellies, vaginal creams, or vaginal medications
for 72 hours before the test, because they could cover up or obscure the cervical cell
sample.
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 Cancel your pap if vaginal bleeding occurs.

Vaginal cancer – is a rare malignant tissue growth arising in the vagina
 Tumors in the vagina commonly occur on the posterior wall and spread to the cervix or
vulva.
 If cancer is localized, radiation, laser surgery, or both may be used
 If cancer has spread, radical surgery might be needed, such as a hysterectomy, or removal
of upper vagina with dissection of the pelvic nodes in addition to radiation.
 Most women with vaginal cancer are asymptomatic; other symptoms include-
 Painless vaginal bleeding (often after sexual intercourse), abnormal vaginal
discharge, dyspareunia, dysuria, constipation, and pelvic pain.
Vulvar cancer – is abnormal neoplastic growth on the external genitalia including the clitoris,
vaginal lips, and opening to the vagina.
 It is the 4th most common Gyn cancer after endometrial, ovarian, and cervical.
 When detected early; it is highly curable.
 Vulvar caner is found most commonly in older women in their mid-60s-70s
 Vulvar cancer is classified into two groups
 Group 1- correlates with a HPV infection and occurs mostly in younger women.
 Group 2 – is not HPV associated and occurs in elderly women without cancerous
disorders.
 (VIN) vulvar intraepithelial neoplasia – precancerous changes
 Annual exams is the most effective way to prevent this type of cancer.
 Leading complaints – dyspareunia, long hx of pruritus, ulcers on the outside genitalia,
vulvar swelling and bleeding, urinary problems.
 Laser surgery, cryosurgery, electrosurgical incision may be used for treatment.
 The traditional treatment is radical vulvectomy.
TAKE NOTE! – vulvar pruritus or a lump is present in the majority of women with vulvar
cancer. Lumps should be bx even if the women is asymptomatic.
Chapter 9
Intimate partner violence (IPV) – is actual or threatened physical or sexual violence or
psychological/ emotional abuse.
 Intimate partners include individuals who are currently dating, cohabitating, or martial
relationships, or those who have been in such relationships in the past with one another.
Generation to generation continuum of violence -violence is a learned behavior that, without
intervention, is self-perpetuation.
 Children who witness one parent abuse another are more likely to come delinquents or
batterers themselves because they see abuse as an integral part of a close relationship.
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 Children who witness IPV are at risk for developing psychiatric d/o, posttraumatic stress
d/o, developmental problems, school failure, violence against others, and low self esteem.
The cycle of violence – comprises three distinct phases
 Phase 1: Tension building – usually the longest – verbal or minor battery occurs. Almost
any subject, such as house keeping or money, may trigger the buildup of tension. There is
a breakdown of communication. The victim feels like “walking on eggshells” around the
abuser.
 Phase 2 Acute battering – explosion of violence. Characterized by uncontrollable
discharge tension; Violence is rarely triggered by victim’s behavior. The battering is
unpredictable and beyond the victim’s control. (assault or murder can/will take place at
this time)
 Phase 3: Honeymoon // reconciliation // calm phase – is a period of calm, loving, contrite
behavior on the part of the batterer. He may be genuinely sorry for the pain he caused his
partner. Abuser is ashamed of his behavior. **the honeymoon phase gradually shortens
and eventually disappears altogether.
Types of Abuse –
 Emotional abuse includes – promising, swearing, or threatening to hit the victim. Forcing
the victim to perform degrading or humiliating acts. Threatening to harm children, pets,
or close friends. Humiliating the women by name-calling and insults. Threatening to
leave her and the children. Isolation from family and friends. Destroying valued property.
Controlling victims every move.
 Physical abuse includes – hitting or grabbing the victim so hard that it leaves marks.
Throwing things at the victim. Slapping, spitting, biting, burning, pushing, choking, or
shoving victim. Attacking the victim with a knife, gun, rope, or electrical cord.
Controlling access to health care for injury.
 Financial abuse includes – preventing women from getting a job, sabotaging a current
job, controlling how all money is spent, failing to contribute financially.
 Sexual abuse – forcing the women to have vaginal, oral, or anal intercourse against her
will. Biting the victims breasts or genitals. Shoving objects into the victims vagina or
anus. Forcing the victim to preform sexual acts on other people or animal.
Abuse profiles –
Victims
 Battered woman syndrome – the women has experienced deliberate and repeated
physical or sexual assault by an intimate partner.
 Abused victim is often terrified and feels trapped, helpless, and alone.
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 May abused victims have poor self-esteem, poor health, PTSD, depression, insomnia,
low education achievement, or a hx of suicide attempts.
Abusers
 Often feels insecure, powerless, and helpless feelings that are not in line with the macho
image. They expresses feelings if inadequacy through violence or aggression toward
others.
 They often exhibit childlike aggression or antisocial behaviors.
 Hx of substance abuse problems, trouble with the justice system, few close friends, holds
grudges, emotionally dysregulated, lacking insight, prone to feeling misunderstood.
TAKE NOTE! – Frequently the fear of harm to her unborn child will motivate a women to
escape an abusive relationship.
Signs of abuse during pregnancy –
 Poor attendance at prenatal visits
 Unrealistic fears
 Weight fluctuations
 Difficult with pelvic exams
 Nonadherence to treatment.
Violence against older women – Elder mistreatment (abuse, neglect) is defined as intentional
actions that cause harm or create a serious risk of harm to a vulnerable elder by a caregiver, or
other person or cares for client.
Types of abuse experienced by the older women =
 Physical abuse, neglect, emotional abuse, sexual abuse, and financial/exploitation abuse.
Box 9.2 save model
SCREEN all of your clients for violence by asking:
 Within the last, year have you be physically hurt by someone?
 Do you feel you are in control of your life?
 Within the last year, has someone forced you to engage in sexual activites?
 Can you talk about your abuse with me now?
 In general, how would you describe your present relationship.
ASK direct questions in a nonjudgmental way:
 Begin by normalizing the topic to the women.
 Make continuous eye contact with the women.
 Stay calm; avoid emotional reactions to what she tells you.
 Never blame the women, even if she blames herself
 Do not dismiss or minimize what she tells you, even if she does.
 Wait for each answer patiently. Do not rush to the next question
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 Avoid using leading questions; be direct and to the point.

 Use a nonthreatening, accepting approach.
 Do use formal, technical or medical language.
VAIDATE the client by telling her:
 You believe her story
 You do not blame her for what happened
 It is brave for her to tell you this
 Help is available for her
 Talking with you is a hopeful sign and a first big step
EVALUATE, educate, and refer this client:
 What type of violence was it?
 Is she now in any danger?
 How is she feeling now?
 Does she know that there are consequences to violence?
 Is she aware of community resources available to help her?
Documentation must include details about the frequency and severity of abuse; the location,
extent, and outcome of injuries; and any treatment options or interventions.
 Use a body map (outline injuries)
 Use direct quotes and be very specific
Successful communication
 Listening – “I hear and understand what you are saying.” Being listened to can empower
women who have abused.
 Communicating belief – “That must have been very frightening for you.”
 Validating the decision to disclose – “It must have been difficult for you to talk about this
today.”
 Emphasizing the unacceptability of this violence – “you don’t deserve to be treated this
way.”
CONCEPT MASTERY ALERT – priorities in intimate partner violence interventions
 Although it is important that the woman is safe, it is most important for a woman to
regain a sense of control in her life. A lack of control is what prevents a women from
escaping an abusive situation.
READ box 9.3 pg 312 – danger assessment tool
Primary prevention – aimed at breaking the abuse cycle.
 Community educational initiatives by nurses, physician and NP, law enforcement officer,
teachers, and clergy.
Secondary prevention – focuses on screening
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 High risk individuals and dealing with victims and abusers in early stages, with the goal
of preventing progression of abuse.
Tertiary prevention – geared toward helping client to recover.
 Severely abused woman and children.
 Rehab programs / shelters / therapy
Box 9.4 The ABCDES for caring for abused woman
 A – is reassuring the woman that she is not alone.
 B – is expressing the belief that violence against woman is not acceptable in any situation
and that it is not her fault.
 C – is confidentiality, since the woman might believe that if the abuse is reported, the
abuser will retaliate.
 D – is documentation which includes the following.
 A clear quoted statement about the abuse in the woman’s own words
 Accurate descriptions of injuries and the hx of them
 Information on the first, the worst, and the most recent abusive incident.
 Photos of the injuries.
 E – is education about the cycle of violence and that it will escalate:
 Educate about abuse and its health effects
 Help her to understand that she is not alone
 Offer appropriate community support and referrals.
 Display posters and brochures to foster awareness of this public health problems
 S – safety, the most important aspect of the intervention, to ensure that the woman has
resources and a plan of action to carry out when she decides to leave.
Teaching guidelines 9.1 safety plan for leaving an abusive relationship
 When leaving take the following items.
 Drivers license or photo ID
 Social security number / green card/ work permit
 Birth certificates for you and your children
 Phone numbers for social services or women’s shelter
 Court orders or documents
 Health insurance cards
 Pay stubs, check books, credit cards, cash
 Change of clothing.
 Develop a “game plan” for leaving and rehearse it.
Sexual violence – includes IPV, human trafficking, incest, FGC, forced prostitution, bondage,
exploitation, neglect, sexual assault.
 Rape has been reported against females from age 6 months to 93 years old
 Symptoms – chronic pelvic pain, headaches, backache, STIs, pregnancy, anxiety, denial,
fear, withdrawal, sleep disturbance, guilt, depression.
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TAKE NOTE! – sexual violence has been called a “tragedy of youth” more than half of all rapes
(54%) of woman occur before age 18
Sexual abuse – forced to have sexual contact of any kind (vaginal, oral, or anal) without consent.
Incest – sexual activity between person so closely related that marriage between them is legally
or culturally prohibited.
TAKE NOTE! – childhood sexual abuse is a trauma that can affect every aspect of the victims
life.
Rape – expression of violence, not a sexual act. Rape distorts one of the most intimate forms of
human interaction.
 It is a violent, aggressive assault on the victim’s body and integrity.
 Rape is a legal rather than a medical term.
Statutory rape – is sexual activity between an adult and a person under the age of 18.
 It is still rape even if the person was WILLING.
Acquaintance rape – someone forced to have sex by a person he or she knows. Rape by a
coworker, a teacher, husband friends, a boss.
Date Rape- as assault that occurs within a dating relationship or marriage without consent of one
of the participants, is a form of acquaintance rape.
 Date rape commonly occurs on college campuses.
 Commonly used drugs – rohypnol (roofies, forget pill) dissolves in liquid with no odor,
taste, or color. 10 times stronger than valium. Effects can be felt within 30 mins.
Produces memory loss for up to 8 hours. Gamma hydroxybutyrate (GHB) – called “liquid
ectasty. Produces euphoria, an out of body experience, and memory loss. GHB takes
affect in about 15 minutes, and last 3-4 hours. Ketamine ( special K, super acid) – acts on
the central nervous system.
Table 9.3 four phases of rape recovery –
 Acute phase (disorganization) – shock, fear, disbelief, anger, shame, guilt, feelings of
uncleanliness; insomnia, nightmares, and sobbing.
 Outward adjustment phase (denial) – appears outwardly composed and return to work or
school; refuses to discuss the assault and denies need for counseling.
 Reorganization – denial and suppression do not work, and the survivor attempts to make
life adjustments by moving or changing jobs and uses emotional distancing to cope.
 Integration and recovery – survivor begin to feel safe, and starts to trust others. She may
become an advocate for other rape victims.
Teaching guidelines 9.2 protecting yourself against date rape drugs.
 Avoid parties where alcohol is being served
 Never leave a drink of any kind unattended.
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 Don’t accept a drink from someone else.

 Accept drinks from bartender or in closed container only.
 If a drink is left unattended, pour it out, don’t drink it.
 Don’t drink anything that smells strange
 If you think someone drugged you call 911
Rape recovery – the time / process of healing from their trauma. Some woman never heal and
never get professional counseling but most can cope.
PTSD symptoms are divided into three groups
 Intrusion – re-experiencing the trauma, including nightmares, flashbacks, recurrent
thoughts.
 Avoidance – avoiding trauma-related stimuli, social withdrawal, emotional numbing.
 Hyperarousal – increased emotional arousal, exaggerated startle response, irritability.
TAKE NOTE! – many rape survivors seek treatment in the hospital emergency department if no
rape crisis center is available. Unfortunately many emergency room dr and nurses have little
training in how to treat rape survivors or in collecting evidence.
PROVIDING SUPPORT – establish a therapeutic and trusting relationship. Provide a change of
clothes, access to a shower and toiletries, and a private waiting area for family and friends.
COLLECTING AND DOCUMENTING EVIDENCE – the victim should be instructed to bring
all clothing worn at the time of assault. The victim should not shower or bathe before care.
ASSESSING FOR STIs – a pelvic exam is done cultures are collected to rule out STIs
PREVENTING PREGNANCY – is an essential element in the care of rape survivors; patient is
usually given EC // one dose taken within 72 to 120 hours.
Female Genital cutting – FGC is defined as procedure involving any injury of the external
female genitalia for cultural or nontherapeutic reasons.
 The most common long-term complication is the formation of inclusion clitoral dermoid
cysts and labial fusion.
 These become large as a grapefruit and can lead to difficulty walking, sitting, and can
cause psychological distress.
Box 9.5 four major types of female genital mutilation procedures
 Type 1 – excision of the prepuce with excision of part or the entire clitoris.
 Type II – excision of the clitoris and part or all of the labia minora
 Type III – infibulation – excision of all or part of the external genitalia and stitching/
narrowing of the vaginal opening.
 Type IV – pricking, piercing, or incision of the clitoris or labia.
 Stretching of the clitoris and /or labia
 Cauterizing by burning the clitoris and surrounding tissue.
 Scraping or cutting the vaginal orifice
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 Introduction of a corrosive substance into the vagina

 Placing herbs into the vagina to narrow it.
Human trafficking – is a violation against human rights, and nurses who suspect it should report
it to stop the cycle of abuse.
The nurses role in dealing with survivors of violence is to establish rapport; open lines of
communication; apply the nursing process; implement and intervene as appropriate.
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OB final Exam Review

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 Stage 5- Adult breast contour; areola recess to breast contour.

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 Metrorrhagia – bleeding between periods

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Box 4.2 Treatment options for PMS and PMDD

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 Depressed mood, feeling or hopelessness

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 Treatment – Doxycycline 100 mg orally bid for 7 days, or azithromycin 1 g orally in a

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 Promote use of barrier methods (condoms, diaphragms)

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 Postmenopausal use of estrogens and progestins

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Adjunctive therapy – is supportive or additional therapy recommend after surgery.

Table 6.5 characteristics of benign versus malignant breast masses

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Benign breast masses are described as:

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 Anterior or posterior colporrhaphy (to repair cystocele or rectocele)

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 Ovulation induction agents (clomid) to treat infertility

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 Endometrial bx is an office procedure; the first step in dx of endometrial cancer

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Table 8.2 Pap Smear Guidelines

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 Cancel your pap if vaginal bleeding occurs.

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 Avoid using leading questions; be direct and to the point.

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 Don’t accept a drink from someone else.

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 Introduction of a corrosive substance into the vagina

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