NUR 120 - wcunurs120and121

Sexually Transmitted Diseases
Reproductive System Disorders
Pelvic Relaxation Disorders
Anatomy of Female Reproductive
System (Internal)
Lateral View
Sexually Transmitted Diseases
 STDs are diseases that can be transmitted during
intimate sexual contact.
 Most prevalent communicable diseases in the US.
 Most cases occur in adolescents and young adults.
- STDs in infants and children usually indicate
sexual abuse and should be reported. The nurse is
legally responsible to report suspected cases of
child abuse.
Nursing Assessment
Please see handouts, include Symptoms and
1. Syphilis ( Treponema Pallidum)
2. Gonorrhea (Neiserria Gonorrheae)
3. Chlamydia ( Chlamydia Trachomatis)
4. Trichomoniasis ( Trichomonas Vaginales)
5. Candidiasis ( Candida Albicans)
6. Herpes Type 2 (herpes Simplex Virus 2)
7. HPV ( Human Papilloma Virus)
8. HIV and AIDS ( Human Immunodeficiency Virus)
Analysis ( Nursing Diagnoses)
 Deficient Knowledge ( specify) related to
 Anxiety related to
 Anticipatory grieving related to
Nursing Plan and Interventions
A. Use a non judgmental approach. Be straightforward
when taking history.
B. Reaasure client that all information is strictly
confidential. Obtain a complete sexual history.
1. Sexual orientation
2. Sexual practices
3. Type of protection (barrier used)
4. Contraceptive practices
5. Previous history of STDs
Nursing Plan and Interventions
C. Develop teaching Plan include:
1. sign and symptom of STDs.
2. Mode of transmission of STDs
3. Reminder that sexual contact should be avoided with anyone
while infected.
4. Concise written instruction about treatment; request a return
verbalization of these instructions to ensure the client has
heard the instructions and understands them.
D. Encourage client to provide information regarding all sexual
E. Report incidents of STDs to appropriate health agencies and
Nursing Plan and Interventions
F. Instruct women of childbearing age about risk to a
a. Gonorrheal conjuctivitis
b. Neonatal herpes
c. Congenital syphilis
d. Oral candidiasis
G. Teach safer sex
Nursing Plan and Interventions
 Safer sex behavior include:
Reduce the number of sexual contacts.
Avoid sex with those who have multiple partners.
Examine genital area and avoid sexual contact if
anything abnormal is present.
Wash hands and genital area before and after
sexual contact.
Use a latex condom as a barrier.
Nursing Plan and Interventions
 Safer sex behavior include: cont.
f. Use water based lubricants rather than oil based
g. Use a vaginal spermicidal gel.
h. Avoid douching before and after sexual contact:
douching increase the risk for infections because the
body’s normal defenses are reduced or destroyed.
i. Seek attention from health care provider
immediately if symptoms occur.
Complications of STD’s
Pelvic Inflammatory Disease (PID)
Ectopic pregnancy
Cancer (associated with HPV)
Fetal and infant death
Birth defects
Mental retardation
AIDS has a set of complications much broader than
the other STD’s
PID ( Pelvic Inflammatory Disease)
 It involves one or more of the pelvic structures.
 The infection can cause adhesions and eventually
result in sterility.
 Manage the pain associated with PID with analgesics
and warm sitz baths.
 Bedrest in a semi-fowler position may increase comfort
and promote drainage.
 Antibiotic treatment is necessary to reduce
inflammation and pain.
Cystocele and Rectocele
Objectives: At the end of this lecture, the student will be
able to:
 Discuss relevant laboratory, diagnostic and therapeutic
procedures concerning Cystocele and Rectocele
 Discuss assessment findings to client with Cystocele
and Rectocele.
 Discuss Plan of Care for client with Cystocele and/or
 Discuss client teaching regarding management of
Cystocele and/or Rectocele
 Definition – is a protrusion of the bladder through the vaginal
Commonly called “bladder drop”, a cystocele refers to the
dropping or sagging of the vagina in the anterior or upper
The pubocervical fascia is connective tissue that is between the
bladder and anterior vaginal wall and serves as its support
The anterior vaginal wall is attached to the cervix at the upper
portion and has attachments to the pubic bone on the lower
 Etiology – caused by weakened pelvic muscles and/or structures.
 For a cystocele with mild s/s medical treatment can be tried.
 Surgery maybe indicated if not successful.
 When the pubocervical fascia detaches from its upper,
lower or lateral attachments a cystocele can occur.
 A cystocele can become large enough to result in a set
of symptoms that may become bothersome.
 The most common symptoms associated with a
cystocele are: tissue protruding from the vagina, pelvic
pressure, loss of ability to empty bladder to
completion, pain with intercourse, positional bladder
voiding, and vaginal pain.
 Definition: It is a protrusion of the anterior rectal wall
through the posterior vaginal wall.
 Etiology – It is caused by a defect of the pelvic
structures or a difficult delivery or forceps delivery.
 Mild s/s can also be medical treatment can also be
tried. If not successful, surgery maybe indicated.
 The rectovaginal septum is the connective tissue that
separates the rectum (bowel) from the vagina.
 Defects in the rectovaginal septum can result in a
 The rectovaginal septum is attached at its upper
portion to the cervix and the lower portion to the
 The perineum is the space between the vaginal
opening and the anus.
 A rectocele occurs when a break in the septum allows
the rectum to push into the vaginal area.
 Symptoms most commonly associated with a rectocele
are: Tissue protrusion from the vagina, pelvic pressure,
inability to empty bowels, pain with intercourse, and
discomfort with physical activities.
Risk Factors for Cystocele
Advanged age (loss of estrogen)
Chronic constipation
Family History
Risk Factors for Rectocele
 Pelvic structure defects
 Difficult childbirth
 Forceps Delivery
 Previous hysterectomy
Diagnostic Procedures
 Cystocele:
Pelvic Examination – reveals a bulging of the anterior
wall when the client is instructed to bear down.
Voiding cystourethrography is performed to identify
the degree of bladder protrusion and amount of urine
Diagnostic Procedures
 Pelvic examination reveals a bulging of the posterior wall
when the client is instructed to bear down
 Rectal examination and /or barium enema reveals presence
of rectocele.
Cystocele : Anterior colporrhaphy – This uses a vaginal
approach, the pelvic muscles are tightened.
Rectocele: Posterior colporrhapy – Using a vaginal perineal
approach, the pelvic muscles are tightened.
Anterior Posterior Repair if surgery for both Cystocele and
Rectocele is indicated.
Nursing Interventions
 Assessments:
- Monitor for signs and symptoms of a Cystocele:
 Urinary frequency
 Urinary urgency
 Stress incontinence
 Urinary tract infection
 Sense of vaginal fullness
- Monitor for signs and symptoms of a Rectocele:
 Constipation
 Hemorrhoids
 Sensation of mass in the vagina
 Pelvic pressure pain
 Difficulty with intercourse.
Nursing Interventions - Preventions
1. Avoid traumatic vaginal childbirth – early and adequate episiotomy.
An episiotomy is a surgical incision made in the area between the vagina and
anus (perineum). This is done during the last stages of labor and delivery to
expand the opening of the vagina to prevent tearing during the delivery of the
2. Inform the client about measures to prevent atropic vaginitis and of the
advantage of prevention.
Atrophic vaginitis (also known as vaginal atrophy or urogenital atrophy)
is an inflammation of the vagina (and the outer urinary tract) due to the
thinning and shrinking of the tissues, as well as decreased lubrication. This is
all due to a lack of the reproductive hormone estrogen.
The most common cause of vaginal atrophy is the decrease in estrogen which
happens naturally during perimenopausal, and increasingly so in postmenopausal stage. However this condition can sometimes be caused by other
3. Advise client at risk to lose weight if obese.
4. Instruct client to eat high-fiber diet and drink adequate fluids to
prevent constipation.
1. Kegel exercises – tightened pelvic muscles for a count of 10, relax
slowly for a count of 10 repeat in sequences of 15 in lying down, sitting,
and standing position.
The aim of Kegel exercises is to improve muscle tone by
strengthening the pubococcygeus muscles of the pelvic floor.
Kegel is a popular prescribed exercise for pregnant women to prepare
the pelvic floor for physiological stresses of the later stages of
pregnancy and vaginal childbirth.
Kegel exercises are said to be good for treating vaginal prolapse and
preventing uterine prolapse in women and for treating prostate
pain and swelling resulting from benign prostatic
hyperplasia(BPH) and prostatitis in men.
Kegel exercises may be beneficial in treating urinary incontinence
in both men and women. Kegel exercises may also increase sexual
Nursing Interventions
2. Estrogen Therapy – to prevent uterine atrophy and
atrophic vaginitis.
 Inform client of client’s risk from complication of
hormone therapy. E.g. cardiovascular or embolic
 Monitor for s/e of estrogen therapy e.g. water retention,
3. Weight loss and changes in diet.
4. Vaginal Pessary – removable rubber, plastic or silicon
device inserted into the vagina to provide support and
block protrusion into vagina.
 Teach client how to insert, remove, and clean the device.
 Monitor for possible bleeding or fistula formation.
Vaginal Pessary
 A vaginal pessary is a removable device placed into the
vagina. It is designed to support areas of pelvic organ
Post – Operative Care
Administer analgesics, antimicrobials, and stool
softeners/laxatives as prescibed.
Provide perineal care at least twice daily following surgery and
after urination or bowel movement.
Apply an ice pack to the perineal area to relieve pain and
Suggest that the client take frequent warm sitz baths to soothe
the perineal area.
A sitz bath is a plastic tub that fits over the toilet and can be
filled with water. Sitting in the warm water for 15 to 20 minutes
can provide relief from the discomfort from hemorrhoids,
fistulas, anal fissures, or an episiotomy. This can be done
by sitting in a bathtub filled with a few inches of water, but
using a plastic sitz bath that fits over the toilet is often more
Post-operative care
5. Provide a liquid diet immediately following surgery
followed by low – residue diet until normal bowel
function returns.
6. Intruct client how to care for indwelling catheter at home
following surgery.
7. Recommend to client to drink at least 2,000 ml of fluid
daily, unless contraindicated.
8. Following removal of the catheter, instruct the client to
void every 2-3 hour to prevent a full bladder and stress on
9. Teach the client how to perform client intermittent selfcatheterization techniques in the event that client is unable
to void.
Post-operative Care
10. Caution the client to avoid straining at defecation, sneezing,
coughing, lifting, and prolonged sitting, walking, or standing
following surgery.
11. Instruct the client to tighten and support pelvic muscles when
coughing or sneezing.
12. Post-operative restrictions include avoidance of strenuous
activity, weight lifting greater than 5 lbs. and sexual intercourse.
 Client may stay in the hospital from 1 to 2 days. Will probably be
able to return to normal activities in about 6 weeks. Avoid
strenuous activity for the first 6 weeks, and increase activity level
 Most women are able to resume sexual intercourse in about 6
Complications and Nursing Implications
 Residual urine in the bladder at risk for recurrent
bladder infection and possibly kidney infections.
 Constipation.
 Dyspareunia (painful sexual intercourse) is a possible
surgical complication due to surgical alteration of the
Needs of Older Adults
 Cystocele and rectocele develop in older female clients
usually following menopause.
 Older clients tend to overuse laxatives and enemas for
the relief of constipation.
 Older adults are more susceptible to post-operataives
 Performing Kegel exercises and manipulating pessary
maybe more difficult for older adults.
NCLEX type of Questions
 The nurse caring for a client who is wearing a pessary
for conservative management of a cystocele knows that
client understood instructions well if the client will
a. “Discomfort from the pessary is expected and should
not be of concern”.
b. “I will report to my physician any change in color,
amount, odor, or consistency of vaginal discharge”.
c. I need to return to my physician for check up
following insertion after 8 weeks”.
d. “I will just re-insert the pessary in the event it falls
Question #2
 What instruction should the nurse provide to the
client concerning clean intermittent selfcatheterization that will limit occurrence of possible
a. Attempt to void prior to catheterization.
b. Wash the perineal area from back to front using
gentle motion.
c. Allow urine to flow until flow stops.
d. Wash hands thoroughly.
Uterine Prolapse
 Uterine prolapse occurs when pelvic floor muscles and
ligaments stretch and weaken, providing inadequate
support for the uterus.
 The uterus then descends into the vaginal canal.
 Uterine prolapse often affects postmenopausal women
who've had one or more vaginal deliveries.
 Damage to supportive tissues during pregnancy and
 Effects of gravity.
 Loss of estrogen and:
 Repeated straining over the years which can weaken pelvic
floor and lead to uterine prolapse.
 Pregnancy and trauma incurred during childbirth,
particularly with large babies or after a difficult labor
and delivery.
 Loss of muscle tone associated with aging and reduced
amounts of circulating estrogen after menopause.
 In rare circumstances, uterine prolapse may be caused
by a tumor in the pelvic cavity.
 Genetics also may play a role in strength of supporting
tissues. Women of Northern European descent have a
higher incidence of uterine prolapse than do women of
Asian and African descent.
Risk Factors
 One or more pregnancies and vaginal births
 Giving birth to a large baby
 Increasing age
 Frequent heavy lifting
 Chronic coughing
 Frequent straining during bowel movements
 Genetic predisposition to weakness in connective tissue
 Some conditions, such as obesity, chronic constipation and
chronic obstructive pulmonary disorder (COPD), can place
a strain on the muscles and connective tissue in the pelvis
and may play a role in the development of uterine prolapse.
Uterine Prolapse
Sign and Symptoms
 Uterine prolapse varies in severity.
 Mild uterine prolapse client may experience no signs or symptoms.
 Moderate to severe uterine prolapse. Client will experience the
following sign and symptomes:
- Sensation of heaviness or pulling in pelvis
- Tissue protruding from your vagina
- Urinary difficulties, such as urine leakage or urine retention
- Trouble having a bowel movement
- Low back pain
- Feeling as if sitting on a small ball or as if something is falling out of
- Sexual concerns, such as sensing looseness in the tone of vaginal
- Symptoms that are less bothersome in the morning and worsen as
the day goes on.
Test and Diagnostic Procedures
 Pelvic exam.
A complete pelvic exam to check for signs of uterine prolapse. –
-Client will be examined while lying down and while standing
up. Your physician may ask client to bear down as if having a
bowel movement to see how much that affects the degree of
To check the strength of your pelvic muscles, client may also be
instructed to contract them, as if you are stopping the stream of
 Imaging tests.
- Imaging tests aren't generally needed for uterine prolapse, but
they're sometimes helpful in assessing the degree of prolapse.
Physician may recommend an ultrasound or magnetic resonance
imaging (MRI) to further evaluate your condition.
Uterine Prolapse - Treatment
 For mild uterine prolapse, treatment usually is not
needed. But if uterine prolapse makes client
uncomfortable or disrupts normal life, client might
benefit from treatment.
 Options include using a supportive device (pessary)
inserted into the vagina or having surgery to repair the
 Losing weight, stopping smoking and getting proper
treatment for contributing medical problems, such as
lung disease with coughing, may slow the progression
of uterine prolapse.
 If client have very mild uterine prolapse, either
without symptoms or with symptoms that aren't
terribly bothersome, no treatment is necessary.
However, pelvic floor may continue to lose tone,
making the uterine prolapse more severe.
 Lifestyle changes
Lifestyle changes may be the first step to ease
symptoms of uterine prolapse:
 Achieve and maintain a healthy weight, to
minimize the effects of being overweight on supportive
pelvic structures.
 Perform Kegel exercises, to strengthen pelvic floor
 Avoid heavy lifting and straining, to reduce
abdominal pressure on supportive pelvic structures.
 Vaginal pessary
A vaginal pessary fits inside the vagina and is designed to
hold the uterus in place. The pessary can be a temporary or
permanent form of treatment.
 Surgery to repair uterine prolapse
If lifestyle changes fail to provide relief from symptoms of
uterine prolapse, or if client prefer not to use a pessary,
surgical repair is an option.
 Surgical repair of uterine prolapse usually requires vaginal
hysterectomy to remove uterus and excess vaginal tissue.
 In some cases, surgical repair may be possible through a
graft of client own tissue, donor tissue or some synthetic
material onto weakened pelvic floor structures to support
your pelvic organs.
Surgical Procedure
Vaginally - generally preferred because vaginal procedures are associated
with less pain after surgery, faster healing and a better cosmetic result.
 However, vaginal surgery may not provide as lasting a fix as abdominal
surgery. If the uterus is not removed during surgery, prolapse can recur.
Laparoscopic techniques — using smaller abdominal incisions, a
lighted camera-type device (laparoscope) to guide the surgeon and
specialized surgical instruments — offer a minimally invasive approach
to abdominal surgery.
 Client might not be a good candidate for surgery to repair uterine
prolapse if still plan to have more children.
 Pregnancy and delivery of a baby put strain on the supportive tissues of
the uterus and can undo the benefits of surgical repair
 Women with major medical problems, anesthesia for surgery might
pose too great a risk.
 Pessary use may be your best treatment choice for bothersome
symptoms in these instances.
 Possible complications of uterine prolapse include:
 Ulcers. In severe cases of uterine prolapse, part of the vaginal
lining may be displaced by the fallen uterus and protrude outside
the body, rubbing on underwear. The friction may lead to vaginal
sores (ulcers). In rare cases, the sores could become infected.
 Prolapse of other pelvic organs. If client experienced uterine
prolapse, client may also have prolapse of other pelvic organs,
including your bladder and rectum.
 A prolapsed bladder (cystocele) bulges into the front part of
client’s vagina, which can lead to difficulty in urinating and
increased risk of urinary tract infections.
 Weakness of connective tissue overlying the rectum may result
in a prolapsed rectum (rectocele), which may lead to difficulty
having bowel movements.

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