Exam 3 Flashcards
Signs of placental separation:
○ Change in uterus shape from discoid to globular (as moves down and contracts)
○ Sudden gush of blood
○ Lengthening of umbilical cord
○ Palpation of tissue in the vagina
Nursing Interventions for Newborn(First Two Hours Recovery)
○ Newborn assessment q30 (fundal assessment and vital signs)
○ Administer erythromycin/vitamin K (eyes/thighs or E/T)
○ Assist with breastfeeding
○ Apgar scoring, weigh, measurements, security bands, education
○ Assist with bonding and feeding initiation
Nursing Interventions for Patient: (First Two Hours Recovery)
○ Start postpartum Pitocin (Oxytocin)
○ Maternal assessments q15 for 1st hour then q30 for 2nd hour (fundal
assessment and vital signs)
○ Pericare, pain medication, comfort measures, assist to bathroom,
education
2-12 hours Postpartum General Protocols: Post-Vaginal Birth
b
● VS and fundal checks q8-12
● Motrin and Tylenol● If epidural, as soon as wears of
●If no epidural, up to bathroom & ambulating right away
●If epidural, as soon as wears off
○May have urinary retention upon first void
●VS and fundal checks q8-12
●Motrin and Tylenol
○ May have urinary retention upon
first void
● VS and fundal checks q8-12
● Motrin and Tylenol
○ May have urinary retention upon
first void
● VS and fundal checks q8-12
● Motrin and Tylenol
Post-Cesarean Birth:
●Bedrest for ~12 hours●Foley catheter●IV fluids infusing●VS and fundal checks q4●Motrin/Toradol and/or PO narcotic
Uterus Assessment: Subinvolution Definition
●a disruption in the normal involution process
○Immediate or delayed; can cause a postpartum hemorrhage or occur due to retained placenta
Why does patient position matter when the RN is completing a fundal massage?
More accurate: as umbilical will be in a different location. Place patient supine
Fundal assessment documentation
○Firm (contracted) or boggy (soft, not contracted)
■Referring to the top of the fundus
○Midline (anatomically corrected) or deviated (pushed to the side) (means bladder is too full)
■Referring to the location of the uterus in the pelvis
○Scant, light, moderate, heavy lochia with or without clots
■Documented of fundus in relation to umbilicus
■Expected to be at the umbilicus day 0 postpartum and move at least 1 fingerbreadth below the umbilicus each day postpartum
■Examples: documented as 1↑U or 2↓U
●Measured in fingerbreadths (FB) above or below the umbilicus
■Concern if the fundus is increasing above umbilicus rather than decreasing below the umbilicus postpartum
BUBBLELE: Bladder
●Significant diuresis in the days following birth
●“Due to void” (DTV) within 4-6 hours after catheterization/most recent void
●Urinary retention is possible
○Increased risk if had epidural anesthesia or cesarean birth
●Burning with urination can occur if laceration/episiotomy
●Risk of UTI remains increased postpartum
○Further increased risk if had a catheter during hospitalization
BUBBLELE: Bowel
●May take up to 3 days before the first bowel movement postpartum
- ○First 3 days: encourage ambulation, fluids, increase fiber-rich foods, stool softener*
- ○3+ days without a bowel movement: discuss with provider alternatives; consider laxative in PO or suppository form and/or enemas*
●Assess presence of flatus: gas
●Post-op cesarean patients can experience trapped gas
○Important to encourage clear liquids first before a large meal postpartum
●Hemorrhoids may have been present in pregnancy
○Often aggravated with pushing in a vaginal delivery
BUBBLELE: Lochia
●Cervical os slowly closes postpartum
●Passing of menstrual-like blood until ~6 weeks postpartum
●Bleeding should slow and follow this pattern. If does not, could be a sign of a complication
- ○Lochia rubra: Days 1-3, bright red, small clots*
- ○Lochia serosa: Days 4-10, brown/pink*
- ○Lochia alba: Day 10+, yellow/white*
●Color and consistency of blood gives insight into origin
BUBBLELE: Episiotomy/Lacerations/Incision
●REEDA is an important acronym when assessing wounds
●Redness
●Eccyhmosis (bruising)
●Edema
●Drainage
●Approximation○Any signs of dehiscence? (separation of wound)
●Assess lacerations from vaginal delivery and post-op incision scar○All sutures usually dissolvable; cesarean incision may have staples
Perineal Lacerations Degrees
●1st-4th degree, ranging from most superficial to deepest
1st degree: through perineal skin only
2nd degree: through perineal muscles
3rd degree: through the anal sphincter muscle
4th degree: through the anal sphincter and rectal mucosa
BUBBLELE: Legs
●Postpartum patients still at high risk for DVTs and now sometimes immobile post-op or not ambulating a lot due to recovery and time spent with newborn
●Assess for edema, varicosities, thrombophlebitis, DVT
●Assess for deep tendon reflexes and clonus if patient is preeclamptic
●Ensure SCD boots applied if patient is not ambulating
BUBBLELE: Emotional Status:
Baby blues: ~80% of patients experience
■Transient feelings of sadness, bouts of crying, overwhelm
■Lasts about 1 week
Rubin’s Model of Maternal Postpartum Adjustment:
●Taking in (dependent phase)○1st 24 hours○Focused on self and basic needs, excited, talkative, reviewing birth experience
●Taking hold (dependent/independent phase)○Lasts 10 days-several weeks○Focused on new role, optimal time for teaching and learning
●Letting go (interdependent phase)○New parent role is accepted, reestablishing relationship with partner, accepting of family unit
Other Postpartum Physiologic Changes: Hormonal
Hormonal Changes:
●Dramatic decrease in estrogen and progesterone
●Lactational amenorrhea related to increase in prolactin and oxytocin with breastfeeding
1st T: Tone (Uterine atony):
●Risk factors: full bladder, large uterus, high parity
●Assessment: boggy uterus; excessive bleeding
●Intervention: fundal massage, uterotonic medications
2nd T: Tissue (Retained placenta)
●Risk factors: preterm delivery, placental abnormalities
●Assessment: boggy uterus; excessive bleeding
●Intervention: Assess for and remove retained products
3rd T: Trauma (Lacerations, episiotomy, hematoma
●Risk factors: precipitous deliveries, OASIS, operative deliveries, macrosomia, abnormal presentation, labial varicosities
●Assessment: firm fundus, steady stream of bright red bleeding, bluish swelling near perineum; intense perineal/rectal pain/pressure
●Intervention: assess the site, hematoma evacuation
4th T: Thrombin (Coagulopathy)
●Risk factors: coagulopathy, placental abruption, OB emergency
●Assessment: bleeding from IV sites/nose
●Intervention: treat underlying cause, transfusions
Uterotonic Medication: (know route/and generic name)
●Oxytocin (Pitocin) IV
○Double rate of normal postpartum Oxytocin
●Misoprostol (Cytotec) PR
○Can cause slight increase in temperature
●Hemabate (Carboprost) IM
○Can lead to diarrhea
○Contraindicated in patients with asthma●
Methergine (methylgonovine maleate) IM
○Contraindicated in patients with hypertension
*bold is generic
Signs and Symptoms of Postpartum Infections:
fever, chills, tachycardia, foul-smelling or looking lochia or drainage, redness
*****If a fever spikes postpartum, we do not refer to it as chorioamnionitis anymore (only when pregnant) and instead endometritis
Postpartum Discharge Teaching: WHEN TO CALL PROVIDER
●Fever > 100.4, pain/redness in leg, abnormal discharge/odor, sudden increase in lochia, preeclampsia signs and symptoms (headache, vision changes, nausea/vomiting, epigastric pain)
Postpartum DVT: Signs and Symptoms of Thrombophlebitis: Inflammation
●Signs and symptoms: redness, warmth, pain, tenderness, edema, fever
●Interventions: elevate, heat, pain meds, SCDs
●Can progress to superficial thrombophlebitis, DVT, pulmonary embolism (PE)
Postpartum DVT: Signs and Symptoms of Thrombosis/DVT: clot formed from inflammation or partial obstruction of a vessel
●Similar signs & symptoms as above
●Similar treatment with addition of strict bedrest and initiation of anticoagulant
Ideal Newborn Vital Signs
●Allow a transition period for vitals to regulate
●Heart rate: 120-160○Brief fluctuations above or below normal depending on sleep/active states
●Temperature: 97.7-99.5 F (36.5-37.5 C)
●Respirations: 30-60
MILD signs of Respiratory Distress
●Nasal flaring
●Grunting
●Retractions (use of intercostal or subcostal muscles “drawing in” of tissue between ribs)
MODERATE/SEVERE Respiratory Distress
●Suprasternal or subclavicular retractions with stridor or gasping
●Seesaw or paradoxical respirations
●Circumoral cyanosis (bluish of lips/mucous membranes)
●Central cyanosis○Late sign of distress indicating hypoxemia
●Apnea > 30 seconds
First thing to do when you see Moderate/Severe Respiratory Distress?
ASSESS!!!
then…call for help.
Transient Tachypnea of the Newborn (TTN)
●Mild TTN occurs 1-2 hours post-birth●
Shows signs of respiratory distress
●May require supplemental oxygen
●Usually resolves within 24 hours
Newborn Thermogenesis:
○Newborns produce heat via nonshivering thermogenesis by metabolizing brown fat and increasing metabolic activity
○Newborns have small reserves of brown fat (the longer the gestation, the more brown fat)■This rapidly depletes with cold stress
Why are newborns more at risk for heat loss?
○Due to smaller surface area, blood vessels close to skin surface, little subcutaneous fat in newborns
Heat Loss: Convection
●Convection: flow of heat from body surface to surrounding cooler air○Example: naked baby in bassinet losing heat to cool air around them rather than being swaddled with a hat
Heat Loss: Conduction
●Conduction: flow of heat from body surface to a cooler surface in direct contact○Example: naked baby lying on a cold scale to be weighed without a blanket on it
Heat Loss: Evaporation
●Evaporation: flow of heat when liquid is converted to a vapor○Most significant cause of heat loss in the days after birth○Example: moisture vaporization from the newborn skin before dried after a bath
Heat Loss: Radiation
●Radiation: flow of heat from body surface to a cooler solid surface nearby (not directly touching)○Example: baby’s bassinet next to a window in the winter months rather than baby being far from window and any air drafts
Because of heat loss by convection: The ambient temperature in newborn care ares should range between what temperature and what humidity?
ambient temperature in newborn care areas should range between 22° and 26° C (72° to 78° F)
the humidity between 30% and 60%
Cold Stress Facts
●Increased physiologic and metabolic demands caused by hypothermia
●Symptoms: hypothermia, pale, mottled, cold skin●Can lead to and exacerbate hypoglycemia, hyperbilirubinemia, respiratory distress
●Avoid by minimizing heat loss and maintaining in neutral thermal environment
GI and Renal System Facts:
●Newborns have diuresis of excess extracellular fluid the first few days after birth○Contributes to expected weight loss < 10% of body weight●
New research is emerging about the microbiome and health and relationship between birthing person and newborn’s microbiomes○Mode of birth affects microbial colonization of the newborn○Additional factors are antibiotic use, diet, and environment
Hepatic System Facts
●Immature at birth
●Liver functions: iron storage, glucose homeostasis, fatty acid metabolism, bilirubin synthesis, coagulation, drug metabolism
●Newborns have high concentrations of red blood cells (RBCs) at birth and these RBCs have shorter life spans → ↑ bilirubin which is a byproduct of RBC hemolysis → ↑ build-up of unconjugated bilirubin that must be broken down by liver
Jaundice:
●Jaundice: yellow discoloration of skin and sclera of eyes○Appears when total serum bilirubin > 6-7 mg/dL○Risk factors: Born <38 weeks, exclusive breastfeeding, prior baby with jaundice, significant bruising during delivery
Can be harder to assess visually in darker-skinned newborns
****Jaundice usually starts in the head and progresses downward to the rest of the body
Bilirubin:
●Bilirubin: waste byproduct produced by RBC hemolysis○Two types: conjugated (easily excreted from the body) and unconjugated (insoluble and must be conjugated in liver to be excreted)
Hyperbillirubinemia is?
high bilirubin
_Acute bilirubin encephalopathy i_s?
●bilirubin toxicity when bilirubin levels are high enough to cross the blood-brain barrier
○Signs and symptoms: lethargy, irritability, seizures, coma, death
Kernicterus: Definition and S/S
●irreversible long-term effects of bilirubin toxicity
○Signs and symptoms: hypotonia, hearing loss, delayed motor skills, cerebral palsy
Icteric:
adjective used to describe being affected by jaundice
●Physiologic jaundice
○Common (occurs in ~60% term, 80% preterm infants)○Due to high levels of unconjugated bilirubin○Presents after 24 hours of life○Usually self-resolves without treatment
Pathologic Jaundice
○Less common○Presents in the 1st 24 hours of life○Usually occurs due to a medical condition and/or severely high levels of bilirubin■Common cause is blood type incompatibility (ABO or Rh incompatibility)
*more severe type of jaundice
●Breastfeeding-associated jaundice (early-onset)
○Occurs at 2-5 days after birth○Hyperbilirubinemia occurs due to lack of effective breastfeeding (breastfeeding itself is not a cause)
●Breast milk jaundice (late-onset)
○Occurs at 5-10 days after birth○Rare, unknown cause but likely factors in breast milk decrease ability to excrete unconjugated bilirubin
Screening for Hyperbilirubinemia
●Part of newborn assessment to inspect for jaundice
●Transcutaneous bilirubinometry (TcB or TcBilli) is a monitor used on the forehead of every baby before hospital discharge○Screening tool only (not reliable if bilirubin > 15)
●If high, will obtain a total serum bilirubin level via heel stick for more accurate measurement
Jaundice Treatment
●Feeding → stooling → way to excrete unconjugated bilirubin○Physiological jaundice typically resolves with increased feeding
●Hyperbilirubinemia related to pathologic jaundice and/or very high levels, may require phototherapy○Light energy used to change shape of bilirubin causing unconjugated → conjugated for easier excretion → reduces circulating bilirubin
●Exchange transfusion: most invasive treatment if phototherapy is not sufficient or if encephalopathy/kernicterus occurs○Performed in NICU where infant’s blood is replaced with donor blood
Phototherapy:
- Phototherapy does not use significant UV radiation. Opaque eye mask prevents retinal damage. Can increase heat loss via evaporation so important infant is still feeding q2-3 hours to prevent dehydration (only a diaper and eye protection) No lotion
- Many factors vary in phototherapy causing a unique experience for each individual baby based on their clinical findings
Goal of phototherapy: “bilirubin level should begin to decrease within 4 to 6 hours after phototherapy is initiated and within 24 hours should decrease by 30% to 40%”
Integumentary System in Baby
●So many NORMAL skin changes! Most self-resolve
●Vernix: prevents heat loss via evaporation; emollient, antimicrobial, and antioxidant properties; also decreases the skin pH, skin erythema, and improves skin hydration (in addition to possibly contributing to a healthy microbiome)- (white cheesy stuff)
●Lanugo:coarse body hair that will fall off
●Creases on the palms and soles of feet●
Milia:-small, whiteheads that look like baby acne
●Peeling (desquamation)
●Port wine stain (red birthmark-doesn’t resolve)
●Harlequin sign-a transient condition where half of the face appears red
●Mongolian spots- blue spots on back of rear end
●Stork bites (nevi)
●Erythema toxicum (newborn rash)
**The soles of the feet should be inspected for the number of creases during the first few hours after birth; as the skin dries, more creases appear. More creases on the palms of hands and soles of feet correlate with a greater maturity rating.
Crytorchidism
failure of testes to descend; more common in preemies)
Hypospadias vs Epispadias
urethra is below tip of penis)
vs
(urethra is above tip of penis)
Molding:
overlapping of cranial bones during birth to allow passage through the birth canal → variations in shape of head
Caput succedaneum:
● “caput” or “cone head” caused by sustained pressure during birth → compression of vessels → ↓ venous return → edema
Cephalohematoma:
●blood collection between skull bone and periosteum○Does not cross suture lines; firmer and more defined than caput○Resolves within 2-8 weeks; usually occurs with caput succedaneum
Subgleal hematoma
can also occur and is rare but more severe; often occurs from the shearing forces of an operative delivery
Apgar Scoring
●Scores given at 1 and 5 minutes of life
●Scores are out of 10○If 5 minute Apgar is <7, will repeat again at 10 minutes of life○If 10 minute Apgar is <7, will repeat again at 15 and then again at 20 minutes (if needed)
●5 criteria, each get a score of 0, 1, or 2○Heart rate, respiratory effort, muscle tone, reflex irritability, color
●Nurse responsibility unless the pediatric team is present for delivery●Acrocyanosis normal in 1st 24 hours
●Apgar scoring does not predict future neurologic outcomes
Apgar Score adaptation:
0-3 severe distress
4-6 moderate difficulty
7-10 adapting
Apgar Heart Rate Score: 0,1,2
0: absent
1: Slow< 100/min
2: > 100/min
Apgar Respiratory Score: 0,1,2
0: absent
1: Slow, weak cry
2: Good cry
Apgar Muscle Tone Score: 0,1,2
0- flaccid
1- Some flexion of extremities
2- Well flexed
Apgar Reflex Irritability Score: 0,1,2
0-No response
1- Grimace
2- Cry
Apgar Color Score: 0,1,2
0-Blue, Pale
1- Body pink, extremities blue
2- Completely Pink
Newborn Growth
At term >37 weeks, average measurements:
●Weight: 2500g-4000g (5.5lbs-8.8lbs)○Described in further detail based on gestational age using a growth chart○
Appropriate for gestational age (AGA): Infants between 10-90th percentile○
Small for gestational age (SGA): Infants <10th percentile○
Large for gestational age (LGA): Infants >90th percentile
●Length: 45cm-55cm
●Head circumference: 32cm-38cm
Newborn Reflexes
●Some reflexes are vital for survival
●Rooting is a sign of hunger, sucking, sneezing, gagging
●Newborns are nasal breathers○~3 weeks a reflex develops causing mouth opening if nose obstructed
●Presence of reflexes reflects neurologic intactness and maturity
I/O’s in Newborns
●Together with daily weights is a great indicator of feeding success
●In the first 3 days of life, the minimum # of expected wet and dirty diapers correlate with how many days old the baby is
●Meconium is first bowel movement and will transition over the next few days○Breast milk fed babies stools: black → green → yellow, seedy (sweet smell)○Formula fed babies stools: brown, thick (bad smell)
●Urine is usually straw colored and odorless○A sign of dehydration is pink-tinged uric acid crystals called “brick dust”
●Spitting up is common and normal. If excessive or appears painful, not normal
Newborn Screening Tests
●Bilirubin test
●Metabolic screening required by the state
●Hearing Test
●Critical Congenital Heart Disease (CCHD): pulse oximetry on two extremities
Routine Metabolic Newborn Screening
●Blood sample obtained via heel stick and sent to external lab○Results communicated with pediatric provider after discharge
●Must be performed after 24 hours for accuracy
●Required by the state
●Examples include phenylketonuria (PKU) and cystic fibrosis
Circumcision
●Optional medical procedure●Often performed by an OB/GYN●Performed after 24 hours of life●Requires “circ care” post-procedure○Involves gauze and vaseline○Monitor bleeding and healing○Continues 7-10 days post-procedure based on pediatric provider’s recommendations
Nursing Interventions:
●Assist with procedure in terms of comfort, gathering equipment, positioning baby, perform time out with doctor, circ care, education to family, assess I&Os
Prematures Risks:
- no fat deposits,
- difficulty maintaining temperature,
- decreased immune activity,
- immature organs (↑ risk for hyperbilirubinemia, ↓ kidney function,
- hypoglycemia)
- Respiratory distress due to absent or decreased surfactant, immature regulatory center, pliable thorax
Necrotizing Enterocolitis (NEC)
●Acute inflammatory bowel disease●
●Bowel swells → breaks down → unable to produce its own natural defenses → ↑ risk bacterial colonization
●Risk factors: preterm infants, formula fed
●Early signs and symptoms nonspecific: fatigue, abdominal distension
●Bowel rest is indicated; when safe to resume feedings, breast milk is best
●Nursing interventions: avoid rectal temperatures, infection control
BABIES MAJOR AT RISK FOR INFECTION!!!
Neurologic Complications
●Risk inversely proportional to gestational age
○Preemies have ↑ fragile cerebrovascular system, ↑ permeability of capillaries, prolonged PTT
●Hypoxic-ischemic brain injury
●Intraventricular or intracranial hemorrhage
○Ruptured vessel from ↑ cerebral blood flow to area
●Treatment: Therapeutic hypothermia appropriate for late preterm and term newborns○Body or head cooling within 6 hours after delivery improves outcomes ○Otherwise supportive measures
Inborn Errors of Metabolism: When do we test for these?
At 24 hours
Neonatal Infections and Sepsis
●A leading cause of neonatal morbidity and mortality●Symptoms often discrete and nonspecific○Important to catch early
Types:
●Early-onset (congenital): within 1 week of birth (often within 72 hours)
○Rapid onset○Inversely related to infant birth weight○Group beta strep (GBS) sepsis most common
●Late onset: occurs later than 1 week after birth (usually 7-30 days postpartum)○Community or hospital-acquired infections○Pneumonia and bacterial meningitis are most common
Symptoms of Sepsis:
●Early symptoms: lethargy, poor feeding, poor weight gain, irritability
●Later symptoms: temperature instability (typically hypothermia), diarrhea, vomiting, decreased reflexes, pallor, mottled skin, respiratory distress symptoms
Drug-Exposed Infants : Symptoms
●Symptoms: tachycardia, fever, diarrhea, projectile vomiting, nasal congestion, hyperactivity, irritability, excessive crying, perspiration, feeding issues
Fetal Alcohol Syndrome Spectrum Disorder
●Fetal alcohol syndrome (FAS)○Physical and behavioral symptoms plus anatomical manifestations
■Abnormal facial features (small eyes, thin upper lip, indistinct philtrum)
■Seizures most common; also jitteriness, increased tone, hyperreflexia, irritability
●Alcohol-related neurodevelopmental disorder (ARND)
○Behavioral and cognitive disabilities
●Alcohol-related birth defects (ARBD)
○Congenital cardiac, musculoskeletal, renal, and/or auditory manifestations
Hemolytic Disorders
●Most often occurs due to isoimmunization (usually Rh incompatibility)
○Less often associated with ABO incompatibility
●Most common reason for pathologic jaundice
What type of fetal heart tracing may be anticipated for Hemolytic Disorders in infants?
Sinousiodal
ABO Incompatibility
●When the birthing person has a different blood type than the baby and antibodies cross the placenta causing hemolysis in the newborn
●Most commonly occurs when birthing person is O and baby is not
○Due to birthing person with O blood type having anti A and B antibodies that can cross placenta
●Wide variability in maternal sensitization to Rh + antigens → wide variability in symptoms/effects
Infants of Diabetic Mothers (IDM)
●“Single most predictive factor of fetal well-being in a baby born to a diabetic mother is their euglycemic status”
○Uncontrolled blood sugars in early pregnancy increase risk of cardiac and CNS anomalies
○Respiratory distress is a concern due to reduced surfactant synthesis related to maternal hyperglycemia
●Hallmark signs and symptoms: macrosomia or LGA (↑ risk for shoulder and labor dystocia) and hypoglycemia○Can occasionally manifest as growth restricted (IUGR) or SGA
Phenylketonuria (PKU): inborn errors of metabolism
● autosomal recessive enzyme deficiency unable to break down phenylalanine requiring strict dietary changes
Congenital hypothyroidism: inborn errors of metabolism
●variety of causes; requires thyroid hormone replacement
Galactosemia: errors of metabolism
autosomal recessive leading to 1 of 3 enzyme deficiencies requiring specific dietary changes
Respiratory Distress Syndrome
●Lung disease characterized by immature lung development●Almost exclusive to preterm infants; insufficient surfactant is main cause
Respiratory Distress Syndrome Symptoms:
Tachypnea, Dyspnea, retractions, crackles, grunting, flaring of nares, cyanosis or pallor, apnea
*with progressed condition deteriorating vital signs including BP, apnea, and body temperature instability
Breast Cancer Risk Factors:
●Similar as other cancers (age, obesity, family or personal history, unhealthy lifestyles)●Earlier menarche or later menopause●Less or later pregnancies/breastfeeding●Dense breast tissue
Perimenopause
●Perimenopause: length of time between the end of regular menstrual cycles until menopause
○Large variation among patients-average length is 4 years
○Transition phase with decrease in ovarian function and hormone production
○Decrease in estrogen → side effects
○Often characterized by irregular periods, vasomotor symptoms (hot flashes), vaginal dryness, insomnia
○Pregnancy can still occur!
Menopause:
●Menopause: the last menstrual period
○Cannot be confirmed until one year of no menses○Marked by a single event
Postmenopause:
●Postmenopause: begins one year after the last menstrual period
○Longest phase
Chlamydia
●Bacterial●Most common reported STI●Majority asymptomatic; post-coital spotting, dysuria, abnormal discharge ●PO antibiotics for patient and their partner is treatment●Pelvic inflammatory disease (PID) is most common complication●Nursing interventions: antibiotic education
Gonorrhea
●Bacterial●Often asymptomatic; yellow/green discharge, menstrual changes; rectal pain; diarrhea●Ceftriaxone IM is treatment●PID is a complication●Nursing interventions: encourage condoms or abstinence until fully treated to prevent reinfection; partners in last 30 days should be screened
Syphilis
●Bacterial●Types/symptoms:○Primary: Painless chancre (lesion)○Secondary: maculopapular rash, lymphadenopathy, condylomata lata ○Tertiary: multi-organ system failure, often preceded by a latent asymptomatic period ●Can progress to next stage and ultimately death if untreated○A J_arisch-Herxheimer reaction_ can occur (severe febrile reaction with headaches and myalgias within 24 hours of Penicillin treatment)●Penicillin G is treatment●Nursing interventions: Education-testing has high false positive and negative rates; monthly follow-up to ensure treatment is successful
Human Immunodeficiency Virus (HIV)
●Incurable virus●HIV progresses to acquired immunodeficiency syndrome when there is depression of cellular immunity●At risk for opportunistic infections and worse disease course is co-infected with HPV●Flu-like response, sore throat, rash, weight loss●Triple drug antiviral or highly active antiretroviral (HAART) keeps viral load under control●Nursing interventions: informed consent, counseling before and after testing, ensure confidentiality, encourage more frequent STI screening
Humanpapiloma virus (HPV)
●Also known as condylomata acuminata or genital warts●Most common sexually-transmitted virus●Types: 100+ strains○Most low-risk strains cause genital lesions○High-risk strains increase risk for genital tract cancers, especially cervical cancer ●Painless lesions, dyspareunia (painful sex), abnormal discharge●HPV and lesions mostly self-resolve; if don’t, colposcopy and/or loop electrosurgical excision procedure (LEEP) remove precancerous cells●Nursing interventions: determine if candidate for HPV vaccine series, educate, ensure up to date with screening
Herpes Simplex Virus
●Type: Incurable virus●Types: HSV-1 (oral) and HSV-2 (anal) but can be transferred via other routes○Primary outbreak: painful and itchy lesions, flu-like symptoms, discharge○Secondary outbreaks: less severe, recurrent lesions●Antiretroviral for episodic or suppressive therapy●In pregnancy, daily preventative treatment in third trimester because outbreak at time of labor requires a cesarean●Nursing interventions: ensure pregnant patients with history start antiretroviral suppression therapy ~36 weeks, educate
Trichomonas
●Protozoan●Most common STI and likely underreported●Often asymptomatic or yellow-green vaginal discharge, dysuria, dyspareunia, petechiae “strawberry spots” on cervix●Antibiotic as treatment●Nursing considerations: educate, reassure
Vaginal Infections: Bacterial vaginosis
●Most common vaginitis●Anaerobic bacteria replacing healthy lactobacilli, changing the vaginal pH●Symptoms include vaginal “fishy” odor, discharge, itching●Nurse must counsel on antibiotic use and lifestyle changes
Vaginal Infections: Yeast (vulvovaginal candidiasis)
●Risk factors: antibiotic use, high sugar diet, diabetes, pregnancy, immunosuppression●Symptoms include itching, white discharge, pain with urination or intercourseNurse must counsel on antifungal and alternative remedies as well as lifestyle changes
***These are NOT sexually transmitted but the change in pH of the vagina when it comes in contact with semen can increase the risk for these vaginal infections
Contraceptive Barrier Methods: Most effective condoms
●Physical barrier preventing semen from entering vagina●Only contraception option that protect against STIs!●Different types:○Male and female condoms○Diaphragm: dome-shaped device that covers cervix○Cervical cap: (Femcap) 3 sizes that acts as a physical barrier over the cervix○Contraceptive sponge: sponge with spermicide and water that fits over cervix; one size fits all●Efficacy: Condoms: typical use (15% failure); Diaphragm: 4-8% with perfect use and 13-17% with typical use plus spermicide (cervical cap less)●Rare side effect of all except condoms is toxic shock syndrome (sunburn-type rash, flu-like symptoms)
●Nursing interventions: condom education; most diaphragms require fit and proper placement ; all except condoms must be kept in place for 6 hours after intercourse so spermicide can work; education about proper use and storage
Spermicides and Phexxi
●Chemical barrier●Recommended for use with diaphragms and cervical caps but NOT condoms●Does not protect well against STIs and if used more than twice daily, has even been found to increase HIV transmission●Different types:○Spermicides: chemicals that reduce sperm motility; many different routes available ○Phexxi: contraceptive gel that alters the vaginal pH; applicator inserted like a tampon within 1 hour before sex; can be used with any other form of birth control to enhance efficacy (except vaginal ring)●Efficacy: spermicides have 15-29% failure rate; Phexxi 86-93% effective ●Nursing interventions: educate, especially about methods that can and can’t be mixed
Combined Hormonal Birth Control Methods
●Suppresses menstrual hormones to prevent ovulation, thickens cervical mucus, and thins uterine lining●Different types: pill, patch, vaginal ring and many different formulations of the pill○Pill: taken daily, may have placebo “sugar” pills○Patch: new patch placed weekly for 3 weeks then 1 week without patch○Vaginal ring: ring inserted for 3 weeks then removed for 1 week●Efficacy: Typical use 91% efficacy (pills), <9% failure rate (patch & vaginal ring)●Side Effects depend on type of pill: depression, nutrient depletion, water retention, decreased libido●Interactions: should not be taken with anticonvulsants, TB drugs, and some HIV meds●Contraindications: history of blood clots, breast cancer, liver disorders, lactation, <6 weeks postpartum, smoking if older than 35 years of age, migraines with aura, surgery with prolonged immobilization, severe hypertension, and diabetes with vascular involvement●Nursing interventions: education, ACHES warning signs, recommend prenatal vitamins to anyone of childbearing age
Combined Oral Contraceptive Warning Signs:
Abdominal pain
Ches Pain
Headaches
Eye problems
Severe leg pain
Progestin-Only Contraception Methods
●Inhibits ovulation by decreasing and thickening cervical mucus, thins endometrial lining, and alters fallopian tube●Different types: pills (“Minipill”), arm implant, shot, intrauterine device○Pill: even more sensitive than COCs and must be taken within the same 3 hours every day○Shot (DMPA): 1 injection every 3 months○Arm Implant (Nexplanon): thin, rod inserted into arm and lasts up to 3 years○IUD (Mirena, Skyla, others): T-shaped device inserted into the uterus and lasts 2-5+ years depending on type●6% failure rate for DMPA shot; for implant and IUD: perfect = typical use ~99% efficacy●Side Effects: Irregular bleeding/spotting; DMPA shot side effects include temporary bone density loss and long return to fertility●Good candidates: those who combined oral contraceptives are contraindicated for●Nursing interventions: reiterate that timing is key for pills, anticipatory guidance about spotting/side effects; administer shot, educate
Intrauterine Devices
●T-shaped attached to strings inserted into uterus through the cervix; hormonal IUDs work the same as progestin-only methods; non-hormonal IUDs work because copper acts as a spermicide and inflames the endometrium●Different types: non-hormonal (copper) and hormonal (progestin-only)●Perfect use = typical use (1.7% failure rate); effective for 2-10 years depending on type●Copper IUD can cause heavier and more painful periods the first year of use; increased risk of PID if infection present at time of insertion; rare risk of uterine perforation upon insertion●Nursing interventions: anticipatory guidance about insertion; educate on signs of infection; instruct on how to check strings to confirm placement
Long-Acting Reversible Contraception (LARCs)
●Arm implants●Intrauterine devices●Perfect use = typical use because no room for “user error” ~99%
Signs of complications of intrauterine devices:
Period late: abnormal spotting
Abdominal pain; pain with intercourse
Infection exposure; abdominal dischage
Not feeling well, Fever or chills
String missing, shorter or longer
Sterilization/Permanent Contraception
●Surgical occlusion of ova (fallopian tubes) and sperm pathways● (vas deferens) or removal of female organs (uterus and/or ovaries)●Different types: male (vasectomy) outpatient procedure or female (tubal ligation procedure)●Perfect use = typical use; failure rate < 57/1,000 for female●Reversal possible for occlusion of pathways but not always successful ●Nursing interventions: client education, ensure male patients follow-up for repeat semen analysis after 3 months; ensure 30 day mandated wait period before signing paperwork and sterilization occurs
