Learning Objectives
1. Describe the rationale, procedure, and nursing implications for the following diagnostic tests: pelvic examination, Pap test, breast examination, mammography, breast ultrasound, and ultrasonography.
2. Define the following: laparoscopy, culdoscopy, colposcopy, cervical biopsy, and conization.
3. Describe the nursing implications for a client who needs a D&C.
4. List the factors involved in the nursing observations of a breast or reproductive disorder.
5. Relate the teaching components associated with each of the following: feminine hygiene and breast selfexamination.
6. Demonstrate in the skills laboratory the following procedures: providing perineal care, providing sitz baths, inserting a vaginal suppository, and performing a vaginal irrigation.
7. Differentiate the following menstrual disorders: amenorrhea, menorrhagia, metrorrhagia, dysmenorrhea, and extreme irregularity.
8. Describe the causes, signs and symptoms, and the teaching components of nursing care for PMS, PMDD and TSS.
9. Identify common client concerns related to menopause and HRT.
10. Define the following structural disorders: vaginal fistula, cystocele, rectocele, prolapsed uterus, and abnormal flexion of the uterus.
11. Differentiate the following disorders: vulvitis, vaginitis, trichomoniasis, candidiasis, bacterial vaginosis, atrophic vaginitis, cervicitis, endometriosis, PID, vulvodynia, and STIs.
12. Compare and contrast ovarian cancer, uterine cancer, and cervical cancer.
13. Identify the preoperative and postoperative nursing care of a client undergoing a hysterectomy.
14. Explain the steps of breast self-examination.
15. Explain the preoperative and postoperative nursing care of a client undergoing breast biopsy, mastectomy, or reconstructive breast surgery.
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IMPORTANT TERMINOLOGY |
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amenorrhea |
gynecology |
metrorrhagia |
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cervicitis |
hysterectomy |
Pap (Papanicolaou) |
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colposcopy |
laparoscopy |
test (smear) |
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conization |
leukorrhea |
pelvic exenteration |
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culdoscopy |
mammography |
prolapse |
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cystocele |
mammoplasty |
rectocele |
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dysmenorrhea |
mastalgia |
sentinel lymph node |
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dyspareunia |
mastectomy |
vaginitis |
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endometriosis |
menorrhagia |
vulvitis |
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Acronyms |
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ACS |
LEEP |
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AP |
OB/GYN |
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CA125 |
PID |
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D&C |
PMDD |
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HRT |
PMS |
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IUD |
STI |
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JP |
TSS |
The medical specialty that focuses on the female reproductive system is called gynecology. Physicians who work in this area are called gynecologists. Gynecologists who also perform childbirth management are called obstetrician-gynecologists (OB/GYN) (see Unit 10).
General nursing interventions involving the female reproductive system include teaching about anatomy, self-care related to hygiene, and breast self-examination. Nurses who are specially trained in sexual counseling may provide more detailed care measures.
The female reproductive system comprises a complex and specialized set of organs.
DIAGNOSTIC TESTS
Pelvic Examination
Generally speaking, every woman past the age of puberty should have a complete pelvic examination, including a Pap test, every 1 to 3 years. When any pathology is present or the woman has a family history of pathology, she should have the examination more than once a year. The pelvic examination offers the healthcare provider an opportunity to visualize the woman’s cervix, vagina, and perineum. A cervical biopsy also can be done during a pelvic examination. Additionally, cauterization, removal, or coagulation of a portion of the cervix using electricity or laser can be performed during a pelvic examination.
In preparation for the examination, ask the client to empty her bladder. Encourage the woman to breathe deeply and relax to minimize the discomfort associated with the examination. Provide the healthcare provider with the necessary equipment, including a water-soluble lubricant, vaginal speculum, and gloves.
After the client is placed in the lithotomy position (Fig.91-1), the healthcare provider examines the client’s external genitalia. Next, the uterus and ovaries are palpated after the healthcare provider inserts a gloved finger into the vagina and places the other hand on the abdomen. The examination also may include rectovaginal examination, in which the healthcare provider places one finger in the client’s vagina and another finger into the client’s rectum. Palpating in this manner allows detection of abnormalities in the rectal area and problems of the posterior genital organs.
FIGURE 91-1 · Lithotomy position. The nurse places drapes around the client to preserve privacy
Laboratory Tests Pap Test
A malignant growth in the uterus or cervix sometimes sheds cancerous cells into uterine and vaginal secretions. Microscopic examination of a smear from these secretions may help detect cancer before symptoms appear. This examination is known as the Pap (Papanicolaou) test or Pap smear. Cervical cancer is one of the most commonly occurring cancers in women. When cervical cancer is found and treated early, it is highly curable. The Pap test is less accurate in detecting cancer of the endometrium or of the uterus. Healthcare providers may recommend annual pelvic examinations (not always including the pelvic smear) for sexually active women. Rationale: A Pap test looks only for cervical cells. A broader assessment of a woman’s reproductive organs includes a breast examination and a pelvic examination (with or without a Pap test), which are included in the standard procedure known as a "pelvic exam."
Key Concept All women with a cervix are at risk for cervical cancer Women who have had a hysterectomy (uterus removed) may still have a cervix and need to have Pap tests.
The nurse may be asked to assist the healthcare provider in performing the Pap test, which is most commonly performed during the pelvic examination. The procedure for positioning the client is the same as for any routine pelvic examination. In addition to equipment needed for the pelvic examination, necessary Pap test equipment includes glass slides and the applicator or Y-shaped wooden stick that is inserted through the speculum to obtain a smear of cervical mucosa. This material is smeared onto the glass slide; a spray fixative is sprayed over the slide so that the specimen adheres to the glass. Pap smear cytology results may be reported in the range of low-grade lesions to high-grade lesions, which may be compared and differentiated from histologic biopsy results described as mild, moderate, or severe dysplasic precancerous cervical lesions.
Nursing Alert Pap tests should be done between a woman’s menstrual periods. Tests are less accurate when a woman is menstruating. Some women have a higher than normal chance of contracting cervical cancer. These women require regular screening, sometimes more often than once a year.
Key Concept All women must understand the importance of regular Pap tests. A woman may not have physical symptoms with early cancer but may have abnormal cells of the cervix, which could be early indicators of cancer Early detection and treatment of cervical cancer is effective in a high percentage of cases. Teach clients that abnormal Pap tests do not necessarily indicate cancer; but further testing and evaluation are necessary
Nursing Alert Several types of cervical cancer are caused by the human papillomavirus (HPV). A vaccine is available that can prevent certain cervical cancers but does not treat cervical cancer if it has developed. Vaccination does not substitute for routine Pap testing and pelvic examinations.
Tests for Endometrial Cancer
A positive Pap test may indicate endometrial cancer. A Pap test can show a false-negative result for this type of cancer. Therefore, aspiration of the endocervix (the internal portion of the cervix) provides more accurate information. A biopsy of the endometrium itself is the best option for accuracy.
Blood Tests
Several blood tests are used in conjunction with biopsy (of the cervix or breast) to determine specific types of cancer. These tests include estrogen and progesterone receptor analysis. Blood tests also determine the effectiveness of cancer treatment. They are not reliable for initial screening to determine whether or not a client has cancer.
Breast Examination
A woman should have a clinical breast examination performed by her healthcare provider at least once a year (more often if she has a cystic disorder). However, if any unusual symptoms appear, the woman should have her breasts examined immediately. Palpation by the healthcare provider is essentially the same as that done by the woman during breast self-examination.
Mammography
Mammography is an x-ray examination of the breasts that is capable of detecting some cancers 1 to 2 years before they reach palpable size.
Professional guidelines may change, but, in general, a baseline mammogram is recommended for women between the ages of 35 and 40 years. Women older than 40 years are encouraged to have a mammogram every year. Routine mammography is strongly recommended for women who have any of the following characteristics:
• Previous cancer
• Cystic breast disorders
• No children or birth of first child after age 30 years
• No breast-fed children
• Family history of breast cancer
• Strong family history of any type of cancer
• Female hormone (estrogen) therapy
• Extreme fear of cancer (need mammography for reassurance)
Procedure. The procedure is simple and does not require the injection of dye. However, a specially trained radiologist must interpret the mammary x-rays.
Some laboratories request that the woman refrain from using deodorant or powder before the test because they may contain zinc or other metals that will interfere with the x-rays. The client wears a gown that opens in front and is asked to remove neck jewelry and clothing above the waist. Help by explaining that she will be asked to assume several positions and that her breasts will be flat on the x-ray plate. A compressor is pressed from above or the side to flatten each breast as much as possible. The procedure may be uncomfortable, but should not be painful.
A more definitive diagnosis can be obtained by xerography (xeroradiography). However, this test exposes the client to higher radiation levels.
Interpretation. Tumors may show up on mammography as denser than normal breast tissue. However, not all breast abnormalities are identified on a mammogram. Mammography only identifies abnormal breast architecture or tumors with calcium deposits (approximately 70% of the breast tumors that can be diagnosed). The radiologist can speculate whether a tumor is malignant or benign based on its shape, location, and size. If a lesion is present, a biopsy is usually done.
Breast Ultrasound
The ultrasound examination can distinguish a breast cyst from a solid mass, which usually requires a biopsy examination to determine malignancy. Breast ultrasound is not used for routine screening. Ultrasound is being used more frequently with young women with dense breast tissue who present with breast lumps.
Breast Biopsy
Breast biopsy definitively determines the presence of cancer. The pathologist examines breast tissue or fluid to determine the presence and type of cancer cells. In the case of tissue, a frozen section is usually done and it is examined microscopically. Breast biopsy can be performed in several ways:
• Aspiration (fine-needle aspiration): Cells from a lump are drawn into a syringe. (In the case of some cysts, fluid is aspirated, collapsing the cyst. Often, this cyst requires no further treatment but, in chronic cystic disease, the procedure may be routinely repeated.)
• Needle biopsy: A needle with a cutting edge is inserted into a lump and rotated to remove a core sample.
• Excisional biopsy: An entire lump is removed and analyzed. If cancer is localized in this lump, no further treatment may be required.
• Incisional biopsy: Part of a lump is removed as a sample.
Other Diagnostic Tests
Abdominal or Pelvic Ultrasonography
Ultrasonography uses high-frequency sound waves directed back at a transducer placed over the client’s abdominal or pelvic region. The sound waves are converted into electrical impulses, which can be viewed on a special monitor. By scanning the abdomen and viewing the results on the screen, the healthcare provider can evaluate reproductive conditions, such as tumors, cysts, and other pelvic diseases. A secondary approach using ultrasound is with a special probe through the vagina (vaginal ultrasound) to view pelvic organs that cannot be seen any other way.
X-ray Examinations
Several x-ray procedures determine patency of the oviducts or the presence of abnormalities in the uterus and oviducts. The most common is the hysterosalpingogram, in which the uterus and oviducts can be visualized following an injection of contrast dye. The ovaries also may be visualized. These procedures are most often necessary to locate the cause of infertility or to determine the presence of a tumor.
FIGURE 91-2 · Laparoscopy The laparoscope is inserted through a tiny incision near the umbilicus.
Laparoscopy
Laparoscopy is a diagnostic technique that provides direct visualization of the uterus and accessory organs, including the ovaries and oviducts (Fig. 91-2).
For this procedure, a small incision is made in the area of the umbilicus, and the abdomen is then distended (insufflated ) with approximately 2 L of carbon dioxide or oxygen. Gas is used because it allows for a clear view of the organs, separate from the intestines. The laparoscope is inserted into the peritoneal cavity, and the internal organs are viewed.
Laparoscopy is usually performed using general or spinal anesthesia. Two or three small incisions may be made in more extensive procedures; an absorbable suture is placed in the incisions.
The client usually ambulates on the operative day. Document client and family teaching. Usually, the woman will be discharged from the day-surgery center to home.
Nursing Alert Following a laparoscopy severe pain, such as "shoulder strap pain,” may be felt as pain under a clavicle. Report pain to the healthcare provider This type of referred pain may result from either gas instilled during the procedure, which is temporarily trapped under the diaphragm, or from blood accumulating under the diaphragm. Gas pain is temporary but is quite uncomfortable. Pain from accumulated blood can be symptomatic of a life-threatening hemorrhage.
Culdoscopy
Culdoscopy furnishes direct visualization of the uterus, oviducts, broad ligaments, colon, and small intestine. An endoscope is passed through the vaginal wall behind the cervix after a small incision is made in the posterior vaginal cul-de-sac. The procedure is usually done in the Operating Room with the client in a knee-chest position. The client may have local, regional, or general anesthesia. Usually, no sutures are involved, and routine postoperative care is given.
During the culdoscopy, photographs may be taken of the cervix and the vaginal vault; cold conization (removal of a cone-shaped portion of the cervix) also may be done. This procedure also is used to diagnose pelvic pain, tubal pregnancy, and pelvic masses.
Colposcopy
High-risk women often are screened routinely with colposcopy, which allows better visualization of the vagina and cervix than with the regular speculum. The colposcope is a lighted, magnifying speculum that is inserted into the vaginal vault. Many believe that the results are more reliable than those from the Pap test. Accurate diagnosis often requires biopsy, however.
Cervical Biopsy
A cervical biopsy involves the microscopic examination of a small piece of cervical tissue. It is performed when the healthcare provider observes cervical irregularities or when a Pap test is questionable. One means of obtaining this tissue is through a punch procedure (punching out a button of tissue for examination).
The loop electrosurgical excision procedure (LEEP) is a common office procedure in which tissue is removed for diagnosis and treatment of cervical abnormalities. A wire loop and a low level of electricity are used to remove a lesion. Minimal bleeding and cramping are the only side effects.
Conization (Cone Biopsy)
Conization is usually done in an operating room with the client under general or spinal anesthesia. The surgeon removes a cone-shaped piece of the cervix for examination. Cold conization is done with a specially cooled knife and it sometimes preserves the cells better. A small percentage of women may have some bleeding after cervical conization. Watch for symptoms. The client also should check for delayed bleeding after the procedure.
Key Concept Some women who have had cervical conizations or other biopsies have difficulty in later pregnancies. They may need a special procedure, called cerclage, to prevent premature dilation of the cervix, leading to a spontaneous abortion (miscarriage).
