Chapter 69 (Unit 6 Interventions II)

breast biopsy

- All breast masses should be evaluated for the possibility of cancer - Procedures used to biopsy breast tissue include needle aspiration, vacuum assisted biopsy, an advanced breast biopsy instrument method, or surgical biopsy - Teach women to report manifestations of infection to their health care provider after endoscopic procedures and biopsies of the breast, cervix, and endometrium

colposcopy

- Allows three dimensional magnification and intense illumination of epithelium with suspected disease - Suited for inspection of a female patients cervical epithelium, vagina, and vulvar epithelium - Can locate the exact site of precancerous and malignant lesions for biopsy

patient history (cont)

- Ask about menses, including age of menarche, cycle frequency and duration, amount of flow, spotting between periods, dysmenorrhea, and premenstrual symptoms - If the patient is of menopausal age, determine the date of her last menstrual period, the presence of climacteric symptoms and any drugs or complementary and alternative therapies used for these symptoms - Ask all women about the presence of vaginal discharge, a history and treatment of STDs, date and the result of the most recent Pap test, breast self examination practices, history of birth control practices, and vulvar self examination practices - Obtain an obstetric history, since women have never had children have higher rates of ovarian, endometrial, and breast cancer - If a young woman began having intercourse at a very early age and/or has multiple sex partners, she is at high risk for cervical cancer - Ask the male patient about testicular changes and self examination practices, problems with urination, discharge from the penis, rectal problems, history and treatment of STDs, and symptoms related to hernias - Ask about sexual functioning, current problems or changes in sexual response, any difficulty with erection or ejaculation, and the use of drugs or treatments - If patients seek medical attention for a problem related ot the reproductive system, ask additional questions to explore the specific concerns - The type of sex practiced directs attention to the specific body are involved

psychosocial assessment

- Ask about sources of support, strengths, and coping reactions to illness or dysfunction - Use nonjudgmental listening to continue development of trust between yourself and the patient, allowing the patient to openly express feelings or concerns A patients personal experiences, culture, and/or spiritual beliefs may influence his or her ability to enjoy a satisfactory sexual life. These factors may include: - Sexual trauma or abuse inflicted during childhood or adulthood - Punishment for masturbation - Psychological trauma - Cultural influences, such as the idea of female passivity during intercourse - Concerns about sexual partners or sexual lifestyle - Use of alcohol or street drugs

reproductive system

- Basic assessment of the male and female reproductive systems should be part of every complete physical assessment - These problems typically affect the need for sexuality, both its physical and psychosocial aspects, and are difficult for many people to discuss - The nurse should be comfortable with his or her sexuality and be nonjudgmental about differences in sexual practices - This chapter reviews the focused reproductive system assessment that a nurse generalist performs - An advanced practice nurse or other health care provider performs the comprehensive reproductive examination

endometrial biopsy

- Both endometrial biopsy and aspiration are used to obtain cells directly from the lining of the uterus to assess for cancer of the endometrium - Biopsy helps assess menstrual disturbances (especially heavy bleeding) and infertility (corpus luteum dysfunction)

CT

- CT scans for reproductive system disorders involve the abdomen and the pelvis - Health care providers can detect and evaluate masses and identify lymphatic enlargement from metastasis - This scan can differentiate sold tissue masses from cystic or hemorrhagic structures

HPV test

- Can identify many high risk types (13) of HPV infection associated with the development of cervical cancer - This test can be done at the same time as the Pap test for women older than 30 years and for women of any age who have had an abnormal Pap test result - It does not take place of the Pap test because it tests for viruses that can cause cell changes in the cervix that, if not treated, could lead to cancer - Women who have normal Pap test results and no HPV infection are at very low risk for developing cervical cancer

cervical biopsy

- Cervical tissue is removed for cytologic study - A biopsy is indicated for an identifiable cervical lesion, regardless of the cytologic findings

discharge

- Discharge from the male or female reproductive tract can cause irritation of the surrounding tissues, itching, pain, embarrassment, and anxiety - Ask about the amount, color, consistency, odor, and chronicity of discharge that may be present from orifices used during sexual activity - Drugs (antibiotics) and clothing (tight jeans, synthetic underwear fabric) may cause or worsen genital discharge - Many types of discharge are caused by STDs or other infection

patient history

- Establish a trusting relationship with the patient - Many patients are hesitant to share their reproductive history or concerns about sexuality - Heterosexual activity should not be assumed - Lesbian, gay, bisexual, transgender, and queer/questioning are often not fully assessed by health care professionals - Assess the patients health habits, such as diet, sleep, and exercise patterns - Assess for alcohol, tobacco, and drug use (prescribed, OTC, and illicit drugs), because libido (sex drive), sperm production, and the ability to have or sustain an erection can be affected by these substances - Ask female patients about the date and result of their most recent Pap test, breast self examination, and vulvar self examination - Determine when male patients older than 50 years had their last prostate examination and prostate specific antigen test - Ask about childhood illnesses that could have an effect on the reproductive system - Ask whether the patient has had any infections - Assess for chronic illnesses or surgeries that could affect reproductive function - Disorders that affect a woman's metabolism or nutrition can depress ovarian function and cause amenorrhea - Ask whether the patient has been treated with radiation therapy - Ask about the prolonged use of corticosteroids, internal or external estrogen, testosterone, or chemotherapy drugs which can lead to reproductive system dysfunction - Data about sexual activity are vital parts of the patients history - Use data about the patients age, gender, and culture to assess the risk for certain diseases and in evaluating the reproductive system

bleeding

- Heavy bleeding or a lack of bleeding may concern the patient - Postmenopausal bleeding needs to be evaluated - Ask the patient to describe the amount and characteristics of abnormal vaginal bleeding - Assess whether the bleeding occurs in relation to the menstrual cycle or menopause, intercourse, trauma, or strenuous exercise - For male patients, ask about the presence of penile bleeding - Ask any patient who has abnormal bleeding about associated symptoms, such as pain, cramping or abdominal fullness, a change in bowel habits, urinary difficulties, and weight changes

masses

- Masses in the breasts, testes, or inguinal area must be evaluated - Patients can sometimes relate changes in character or size of masses to menstrual cycles, heavy lifting, straining, or trauma - Ask about associated symptoms such as tenderness, heaviness, pain, dimpling, and tender lymph nodes

assessment of the male reproductive system

- Men are often embarrassed and anxious when the reproductive system is assessed - Patient may be concerned about discomfort, the developmental stage of his genitalia, or the possibility of an erection during the examination - Explain each step of the assessment procedure before it is performed - Patient needs to be reassured that the health care provider will stop and change the assessment plan or technique if the patient experiences pain during the examination - Teach relaxation techniques and provide nonjudgmental support during the examination to increase comfort - Testicular cancer is one of the most common cancers in young men, while prostate cancer is common in older men, and both can be treated effectively if found early

lab assessment

- Pap test - HPV test - Serum levels of FSH, LH, and prolactin are helpful in the diagnosis of male and female reproductive tract disorders - Serum testing can also detect estrogen, progesterone, and testosterone levels in men and women - Serologic studies detect antigen antibody reactions that occur in response to foreign organisms. This form of diagnostic testing is helpful only after an infection has become well established - Serologic testing can be used in the evaluation of exposure to organisms causing syphilis, rubella, and herpes simplex virus type 2 - The prostate specific antigen (PSA) test is used to screen for prostate cancer and to monitor the disease after treatment - Elevated PSA levels may be associated with prostate cancer - The Veneral Disease Research Laboratory serologic test for syphilis and the rapid plasma reagin test are used to detect, confirm, and monitor cases of a syphilis infection - These tests are recommended for all pregnant women and person at high risk - HIV testing should be offered to all patient ages 19 to 64, especially those with personal risk factors and adolescents who have been sexually active - Cultures obtained for any discharge or orifice of the male or female identify pathogenic organisms and are used to determine the correct antibiotic therapy

pain

- Patients often seek medical attention as a result of pain, bleeding, discharge, and masses - Ask the patient to describe the nature of the pain, including its type, intensity, timing and location, duration, and relationship to menstrual, sexual, urinary, or GI function - Assess the factors that exacerbate or relive the pain - Ask about sleeping patterns and if pain or other symptoms affect the ability to get adequate rest

assessment of the female reproductive system

- Perform a focused assessment related to specific concerns of the patient - Immediately before the pelvic and breast examinations, ask the patient to empty her bladder and undress completely - Provide as much privacy as possible for patients undergoing examination or testing of the reproductive system - The physical examination of the female reproductive system includes the breasts, cardiovascular system, and abdomen - Inspection of the female genitalia and the pelvic examination are usually performed at the end of a head to toe physical assessment. The patient is more apprehensive about these portions of the examination than about any other part - The woman should not douche or have unprotected vaginal intercourse for at least 24 hrs before the pelvic examination, because doing so may prevent an accuate evaluation of specimens - After the breast examination, the examiner completes the thoracic and cardiovascular examinations and then inspects, auscultates, and palpates the abdomen - The examiner adheres to standard precuations, such as wearing gloves, to protect against possible disease and potential cross contamination from other patients Other than determining pregnancy or infertility, a pelvic examination is indicated to assess for: - Menstrual irregularities - Unexplained abdominal or vaginal pain - Vaginal discharge, itching, sores, or infection - Rape trauma or other pelvic injury - Physical changes in the vagina, cervix, and uterus

breasts

- The female breasts are a pair of mammary glands that develop in response to secretion from the hypothalamus, pituitary gland, and ovaries - The breasts are an accessory of the reproductive system that nourish the infant after birth

external genitalia

- The female reproductive system is located both outside (external) and inside (internal) the body - The external female genitalia, or vulva, extend from the mons pubis to the anal opening - The mons pubis is a fat pad that covers the symphysis pubis and protects it during coitus - The labia majora are two vertical folds of adipose tissue that extend posteriorly from the mons pubis to the perineum - The skin over the labia majora is usually darker than the surrounding skin and is highly vascular. It protects inner vulval structures and enhances sexual arousal - The labia minora are highly vascular and have a rich nerve supply - The clitoris is a small, cylindric organ that is composed of erectile tissue with a high concentration of sensory nerve endings. During sexual arousal, the clitoris becomes larger and increases sexual sensation - The vestibule is a longitudinal area between the labia minora, the clitoris, and the vagina that contains Bartholin glands and the openings of the urethra, Skene's glands (paraurethral glands), and vagina - The area between the vaginal opening and the anus is the perineum. The skin of the perineum covers the muscles, fascia, and ligaments that support the pelvic structures

male reproductive system

- The male reproductive system also consists of external and internal genitalia - The primary male hormone for sexual development and function is testosterone - Testosterone production is fairly constant in the adult male - Low testosterone levels decrease muscle mass, reduce skin elasticity, and lead to changes in sexual performance - The penis is an organ for urination and intercourse consisting of the body or shaft and the glans penis (the distal end of the penis). - The glans is the smooth end of the penis and contains the opening of the urethral meatus - The urethra is the pathway for the exit of both urine and semen - A continuation of skin covers the glans and folds to form the prepuce (foreskin) - The scrotum is a thin walled, fibromuscular pouch that is behind the penis and suspended below the pubic bone. This pouch protects the testes, epididymis, and vas deferens in a space that is slightly cooler than inside the abdominal cavity - The testes area pair of oval organs in the scrotum that produce sperm and testosterone - The epididymis is the first portion of a ductal system that transports sperm from the testes to the urethra and is a site of sperm maturation - The vas deferens is a firm muscular tube that continues from the tail of each epididymis. The end of each vas deferens is a reservoir for sperm and tubular fluids - The prostate gland is a large accessory gland of the male reproductive system that can be palpated via the rectum. The gland secretes a milky alkaline fluid that adds bulk to the semen, enhances sperm movement, and neutralizes acidic vaginal secretions

internal genitalia

- The vagina is a hollow tube that extends from the vestibule to the uterus - The uterus (or "womb") is a thick walled, muscular organ attached to the upper end of the vagina - The upper segment of the uterine body, between the insertion sites of the fallopian tubes, is referred to as the fundus - The cervix is a short narrowed portion of the uterus and extends into the vagina - The fallopian tubes (uterine tubes) insert into the fundus of the uterus and extend laterally close to the ovaries. They provide a duct between the ovaries and the uterus for the passage of ova and sperm - The ovaries are a pair of almond shaped organs located near the lateral walls of the upper pelvic cavity. These small organs develop and release ova and produce the sex steroid hormones (estrogen, progesterone, androgen, and relaxin). Adequate amounts of these hormones are needed for normal female growth and development and to maintain pregnancy

prostate biopsy

- When prostate cancer is suspected, a biopsy must be performed of the prostate gland for histologic study - This can be done by transurethral biopsy, by inserting a needle through the area of skin between the anus and scrotum, or most commonly by transrectal biopsy - Assess cultural issues when identifying risks for certain reproductive problems as well as when evaluating health promotion practices

Pap test

- a cytologic study that is effective in detecting precancerous and cancerous cells within the female patients cervix. It is done immediately before the pelvic examination - Should be scheduled between the patients menstrual periods so that the menstrual flow does not interfere with laboratory analysis - Teach women not to douche, use vaginal medications or deodorants, or have sexual intercourse for at least 24 hrs before the test because these may interfere with test interpretation - The American Cancer Society advises all women to begin having an annual Pap test at 21 years of age - Ages 21 to 29 should have a Pap test every 3 years - Women between ages 30 and 65 should have a Pap test plus a HPV test ("co-testing") every 5 years

cytologic vaginal cultures

- detect bacterial, viral, fungal, and parasitic disorders - Examination of cells from the vaginal walls can evaluate estrogen balance

laparoscopy

- is a direct examination of the pelvic cavity through an endoscope - This procedure can rule out an ectopic pregnancy, evaluate ovarian disorders and pelvic masses, and aid in the diagnosis of infertility and unexplained pelvic pain - May be used instead of a laparotomy for minor surgical procedures because it uses small incisions, involves less discomfort, and does not require overnight hospitalization Laparoscopy is also used during surgical procedures such as: - Tubal sterilization - Ovarian biopsy - Cyst aspiration - Removal of endometriosis tissue - Lysis of adhesions around the fallopian tubes - Retrieval of "lost" intrauterine devices

hysteroscopy

- is a procedure that uses a fiberoptic camera to visualize the uterus to diagnose and treat causes of abnormal bleeding - Can also be used before and during other procedures (laparoscopy) for infertility and unexplained bleeding - Diagnostic hysteroscopy is used to diagnose new problems with the uterus or to confirm results from other tests

ultrasonography

- is a technique that is used to assess fibroids, cysts, and masses - Used to monitor the progress of tumor regression after medical treatment - Helpful in differentiating solid tumors from cysts in breast examinations - In men, ultrasound can test for varicoceles, scrotal abnormalities, and problems of the ejaculatory ducts and seminal vesicles and the vas deferens

mammography

- is an xray of the soft tissue of the breast - Assesses differences in the density of breast tissue - Helpful in evaluating poorly defined masses, multiple masses or nodules, nipples changes or discharge, skin changes, and pain - Can detect about 80 to 90% of cancers that are not palpable by physical examination - Some cancers may not appear on mammography or may appear as benign - In young womens breasts, there is little difference in the density between normal glandular tissue and malignant tumors, which makes the mammogram less useful for evaluation of breast masses in these women - In older women, the amount of fatty tissue is higher and the fatty tissue appears lighter than cancers

hysterosalpingogram

- is an xray that uses an injection of a contrast medium to visualize the cervix, uterus, and fallopian tubes - Used to evaluate tubal anatomy and patency and uterine problems such as fibroids, tumors, and fistulas - This study should not be attempted for at least 6 weeks after abortion, delivery, or dilation and curettage - Other contraindications include UTI and uterine bleeding - Best performed in the fist half of the patients menstrual cycle, which reduces the change that the patient may be pregnant - Ask about allergies to iodine dye or shellfish - Dye is injected through the cervix to fill and highlight the interior of the cervix, uterus, and fallopian tubes - If the fallopian tubes are patent, the contrast material spills into the peritoneal cavity - The patient may experience pelvic pain after the study and should receive analgesic medications as ordered - May also have referred pain to the shoulder because of the irritation of the phrenic nerve - Provide a perineal pad after the test to prevent soiling of clothes as the dye drains form the cervix - Instruct the patient to contact the health care provider if bloody discharge continues for 4 days or longer and to immediately report any signs of infection, such as lower quadrant pain, fever, malodorous discharge, or tachycardia

external genitalia

- mons pubis - labia majora - labia minora - clitoris - vestibule

MRI

- uses a magnetic field and radiofrequency energy to scan for pelvic tumors or to diangose breast cancer in susceptible women - Distinguishes between normal and malignant tissues - Used in addition to mammograms to asses for breast cancer in women who have a genetic risk - may reduce the need for biopsy

internal genitalia

- vagina - uterus - cervix - fallopian tubes - ovaries

reproductive changes associated with aging

Age affects the function of both the male and the female reproductive systems

PSA (prostate specific antigen)

Men: 0 - 2.5 - Increased levels may indicate prostatitis, benign prostatic hyperplasia, prostate cancer

progesterone

Men: 10 - 50 Women: 300 - 2500 - Decreased levels in women indicate possible inadequate luteal phase, amenorrhea - Elevations in women indicate possible ovarian luteal cysts - Decreased levels may indicate ovarian neoplasm, ovarian dysfunction

testosterone

Men: 280 - 1080 Women: < 70 - Increased levels in men indicate possible testicular tumor, hyperthyroidism - Decreased levels in men indicate possible hypogonadism - Elevations in women indicate possible adrenal neoplasm, ovarian neoplasm, polycystic ovary syndrome

bleeding

NURSING ASSESSMENT - Presence of absence of bleeding - Character and amount of bleeding - Relationship of bleeding to events or other factors (menstrual cycle) - Onset and duration of bleeding - Presence of associated symptoms, such as pain

discharge

NURSING ASSESSMENT - amount and character of discharge - presence of genital lesions, bleeding, itching, or pain - presence of symptoms or discharge in sexual partner

masses

NURSING ASSESSMENT - location and characteristics of mass - presence of associated symptoms, such as pain - relationship to menstrual cycle

pain

NURSING ASSESSMENT - type and intensity of pain - location and duration of pain - factors that relieve or worsen pain - relationship to menstrual, sexual, urinary, or GI function - medications