Health Assessment & Health Promotion Flashcards
Purpose of the Health Care Visit:
Evaluate for presence of menopause-related signs & symptoms.
Identify risk factors for osteoporosis.
Institute preventive measures for osteoporosis.
Identify risk factors for cardiovascular disease.
Perform a physical exam to screen for coincidental medical and/or gynecological disease.
Teach women preventive measures for common symptoms of menopause.
Purpose of Health Care Visit:
Provide an opportunity for women to discuss feelings about body image, emotional issues, life style changes, and sexuality.
Institute medication therapy when appropriate.
Hormone therapy.
Bisphosphonates.
Raloxifene.
Patient education.
Initiate preventive health measures as appropriate.
History Taking:
Comprehensive health history with emphasis on following areas:
Woman’s impression of her physical condition and elicit problems relating to:
Presence of hot flushes.
Night sweats.
Insomnia.
Vaginal itching & irritation, dyspareunia.
Angina, palpitations.
Urinary tract problems.
Osteoporotic changes.
Woman’s current physical status:
LMP – R/O possibility of pregnancy.
Presence of abnormal vaginal bleeding.
Current medications, cigarette use, and alcohol intake.
Ongoing treatment for other health problems.
Nutrition, weight control, diet.
Domestic violence.
Emotional issues.
Personal history for:
Cardiovascular problems, hypertension.
Screening for fracture risk:
Bone mass at any point in life is a function of what has already been formed and what has been lost.
Women who haven’t formed adequate peak bone mass in their younger years are at severe risk for fractures later on
Personal History
medical problems that occurred during the adolescent growth spurt:
Disorders that delay or disrupt menstrual function.
Severe dietary deficits.
Physical immobilization.
A careful history can help determine patients who are more likely to be near “fracture threshold” → bones are so brittle that they can snap with a cough or lifting a grocery bag.
Medical History
Breast disorders. Liver disease or tumors. Gallbladder disease. Uterine disorders i.e. -- endometrial cancer, fibroids, previous abnormal pap, history of abnormal vaginal bleeding. Insulin-dependent diabetes.
Family history:
Coronary artery disease.
Breast disease.
Osteoporosis (especially in patient’s mother).
Physical Assessment
Baseline height – take actual measurement.
Weight.
Vital signs - Blood pressure, pulse, respirations.
Comprehensive physical exam.
physical assessment GU
evaluate for menopausal changes:
Assess vagina for signs of atrophy.
Evaluate vaginal muscle tone, presence of cystocele or rectocele.
Evaluate uterine size, shape, & consistency.
A pap smear must be taken adequately to sample squamocolumnar junction which recedes into the cervical canal.
Evaluate adnexa → any palpable adnexa must be referred to MD for evaluation.
Laboratory Assessment
Annual CBC.
FSH level?
In premenopausal women gonadotropic levels fluctuate throughout the transition from last regular period to menopause.
FSH & LH increase during a hot flash but when flush disappears, levels return to those characteristic of young, cycling women
Assessment and amenorrhea
No definitive way to distinguish transient amenorrhea from the amenorrhea that defines menopause.
Obtaining serum hormone assays not of much predictive value during menopausal transition → may still have further ovulatory cycles despite an elevated FSH or low estradiol level.
In the first year after menopause, FSH levels are 10-15X higher than in early follicular phase levels in young woman.
Lab values
Blood lipids - annually or prn. Fasting plasma glucose every 3 - 5 years for women with one or more of the following risk factors: Family history. Obesity. History of gestational diabetes. Liver function studies prior to initiation of HT. Thyroid testing: Every other year after age 60.
Pap Test
After age 30 with 3 normal pap results in a row repeat pap every 2-3 years.
Women over 70 with 3 or more consecutive normal pap results in last 10 years may chose to stop cervical screening.
Screening after total hysterectomy (with removal of cervix) not necessary unless surgery was done as a treatment for cervical cancer.
Mammogram:
Every 1-2 years for women between 40-49 & yearly for those with risk factors.
Annually for women over 50 years of age.
Colorectal testing:
Annual stool specimen - evaluate for occult blood.
Colonoscopy
Every 3-5 years after the age of 50 in patients with average risk of colorectal cancer.
Annually for patients with a history or family history of colorectal cancer.
Bone density testing:
Height loss not evident until bone loss is 25%
DEXA scan – dual energy xray absorptiometry
Most accurate & safest way to measure bone density in order to detect or manage osteoporosis.
Scan site should be determined by history or specific risk factors.
Proximal femur → best single determinant of high fracture risk.
Management Plan for Women with Normal Exam
- Provide contraception during climacteric phase.
OC’s safe in non-smoking women over 35 up to time of menopause. - Always rule out pregnancy with amenorrhea until diagnosis of menopause is made.
- Teach SBE, schedule yearly mammograms.
- Schedule baseline DEXA scan; or repeat scan prn.
- Schedule colonoscopy prn.
Management Plan for Women with Normal Exam
- Teach Kegel exercises. (50-100 every day)
Strengthens support muscles.
Minimize urinary tract problems. - Advise continued, regular sexual activity.
Helps to prevent atrophic vaginitis.
Management Plan for Women with Normal Exam
- Nutritional counseling:
Good nutrition → helps to alleviate symptoms & enhances quality of life.
Well-rounded low fat diet.
Weight control.
Diet full of “high-stress” foods (i.e. - sugar, fat, alcohol, caffeine) can accelerate health problems related to the aging process.
Include food sources of calcium, use supplementation as needed.
Soy products can be a source of estrogen.
Management Plan for Women with Normal Exam
- Educate about the importance of regular exercise.
Prevent/alleviate symptoms of osteoporosis.
Cardiovascular health.
10.Educate about what is “normal” during this stage of life.
Physically.
Psychologically.
Encourage use of support groups to discuss the different aspects of this stage of life.
Management Plan for Women with Normal Exam
- Stress the importance of regular health care visits to practitioner.
- Instruct patient to return for any worsening menopausal symptoms.
- Discuss:
Risks/benefits of hormone therapy (HT); hormone replacement therapy (HRT).
Current recommendations on its use in the management of menopausal symptoms.
Provide informed consent for any women choosing to use HT.
Informed consent must also include discussion of WHI findings.
Osteoporosis Management:
Prevention – educate young women and their parents about importance of good nutrition & regular exercise.
Osteoporosis Management:
Provide calcium intake adequate to prevent bone loss:
Adequate intake:
1000mg/day – perimenopause; women on HT.
1200mg/day – women over age 50
1,500mg/day – women not taking HT; women over age 65.
Optimal source of calcium is dietary especially dairy products.
The average diet has 400mg of elemental calcium/day.
8oz milk 300mg elemental calcium.
Calcium carbonate has 400mg elemental calcium in 1000mg.
Tums has 200mg of calcium per tablet.
Vitamin D to diet
Helps to maintain blood calcium levels in normal range.
If vitamin D is lacking, calcium is not well-absorbed.
Vitamin D – synthesized from skin’s exposure to UV rays in sunlight.
@ 15 minutes of sun exposure daily is considered adequate.
For women at risk of inadequate sun exposure:
400 I.U. daily – age 51-70
600 I.U. daily – over 70
Vitamin D
Vitamin D – can be toxic in high amounts:
Tolerable upper limit → 2000 I.U. daily
Most people should avoid daily amounts over
1000 I.U. daily.
Dietary options:
Egg yolks, liver & oily fish (herring, salmon).
Fish oil (cod liver oil) – 1 teaspoon = 1100 I.U. vitamin D.
Milk fortified with vitamin D = would have to drink 1 quart of milk to = 400 I.U.
Osteoporosis Guidelines (cont)
Regular weight-bearing exercise.
Diet should not be excessive in fiber, protein, & carbohydrates these foods interfere with calcium absorption.
Stop smoking.
Decrease caffeine & alcohol intake.
Medications:
for osteoporosis
Non-hormonal bisphosphonates
Prevention or treatment.
Increases bone mass in lumbar spine & reduces fracture incidence.
Must be taken on an empty stomach at least 30 minutes prior to breakfast & only with water.
Must remain upright at least 30 minutes & until after the first food of the day to avoid irritation to the esophagus.
Medication for osteoporosis
Fosamax
Prevention – 5 mg daily or 35 mg weekly.
Treatment – 10 mg daily or 70 mg weekly.
Fosamax plus D
Treatment – 70 mg/2800 I.U. once weekly.
Boniva
Prevention/treatment – 2.5 mg daily or 150 mg once monthly.
Actonel
Prevention/treatment – 5 mg daily or 35 mg weekly.
Actonel with calcium
Prevention/treatment – 35 my once weekly on day 1, then 500 mg calcium once daily on days 2-7 each week.
