GYNECOLOGIC NURSING

ANATOMY RECALL
FEMALE REPRODUCTIVE SYSTEM: EXTERNAL STRUCTURES ( VULVA/ PUDENDUM)

A. MONS PUBIS OR MONS VENERIS

= PAD OF FAT OVER THE SYMPHYSIS PUBIS. HAIRLESS & SMOOTH IN CHILDHOOD, IT IS COVERED BY DARK & CURLY HAIR CALLED ESCUTCHEON AFTER PUBERTY. HAIR PATTERN IS TRIANGULAR WITH BASE UP. B. LABIA MAJORA = LENGTHWISE, TWO THICK FOLDS OF FATTY SKIN EXTENDING FROM THE MONS TO THE PERINEUM THAT PROTECTS THE LABIA MINORA, URINARY MEATUS AND VAGINAL MUCOSA.

C. LABIA MINORA

= THINNER, LENGTHWISE FOLDS OF HAIRLESS SKIN, ENCIRCLING THE CLITORIS ANTERIORLY (PREPUCE) AND UNITE POSTERIORLY ( FOURCHETTE) .BELOW THE PREPUCE IS CALLED FRENULUM. HIGHLY SENSITIVE TO MANIPULATION AND TRAUMA, THE REASON WHY IT IS OFTEN TORN DURING DELIVERY.
D. VESTIBULE = TRIANGULAR SPACE LOCATED BETWEEN THE LABIA MINORA CONTAINING VAGINAL INTROITUS, URETHRAL MEATUS BARTHOLINS & SKENES GLANDS

E. GLANS CLITORIS = SMALL ERECTILE STRUCTURE; CONTAINS NERVE ENDINGS, SENSITIVE TO TEMPERATURE AND TOUCH. IT IS THE SEAT OF SEXUAL AROUSAL AND EXCITEMENT IN FEMALES. IT IS THE MOST SENSITIVE PART OF A WOMANS BODY. IT IS ALSO THE STRUCTURE THAT GUIDES THE NURSE TO THE URINARY MEATUS.

F. URETHRAL MEATUS = THE EXTERNAL OPENING OF THE URETHRA. SLIGHTLY BEHIND AND TO THE SIDE ARE THE OPENINGS OF THE SKENES GLANDS (PARAURETHRAL GLANDS); THE SECRETIONS OF WHICH HELP TO LUBRICATE THE EXTERNAL GENITALIA. THE SHORTNESS OF THE FEMALE URETHRA MAKES WOMEN MORE SUSCEPTIBLE TO UTI THAN MEN. G. HYMEN . = A TOUGH BUT ELASTIC SEMICIRCLE OF TISSUE THAT COVERS THE OPENING TO THE VAGINA. THE REMNANT OF HYMEN IS CALLED CARUNCULAE MYRTIFORMIS.

Imperforate hymen:
Lack of opening in the vaginal hymen No menstrual bleeding Enlarged uterus

S/S
Amenorrhoea Cryptomenorrhea -A condition where menstrual products are
prevented from exiting the body by a partial or complete obstruction.

Dyspareunia Female infertility Haematocolpos- An accumulation of menstrual blood in the

vagina

Haematometra -An accumulation of blood in the uterus Hydrometrocolpos -accumulation of secretions in the vagina and
uterus

TREATMENT
Medical therapy has no role in the management of imperforate hymen SURGICAL MANAGEMENT
Hymen incision

H. VAGINAL ORIFICE / INTROITUS = EXTERNAL OPENING OF THE VAGINA, COVERED BY A THIN MEMBRANE ( HYMEN) IN VIRGINS.LOCATED LATERAL TO THE VAGINAL OPENING ON BOTH SIDES ARE THE BARTHOLINS GLANDS ( VULVOVAGINAL GLANDS). IT LUBRICATES THE EXTERNAL VULVA DURING COITUS AND THE ALKALINE PH OF THEIR SECRETION HELPS TO IMPROVE SPERM SURVIVAL IN THE VAGINA. THE GRAFENBERG OR G-SPOT IS A VERY SENSITIVE AREA LOCATED AT THE INNER ANTERIOR ASPECT OF THE VAGINA.

I. FOURCHETTE
= THIN FOLD OF TISSUE FORMED BY MERGING OF THE LABIA MAJORA AND LABIA MINORA BELOW THE VAGINAL ORIFICE. J. PERINEUM = MUSCULAR SKIN COVERED AREA BETWEEN VAGINAL OPENING AND ANUS.

INTERNAL STRUCTURES: A.VAGINA HOLLOW MEMBRANOUS & MUSCULAR CANAL, 3-4 INCHES LONG,DILATABLE, CONTAINS RUGAE (WHICH PERMITS CONSIDERABLE STRETCHING WITHOUT TEARING).IT IS LOCATED IN FRONT OF THE RECTUM & BEHIND THE BLADDER. = PASSAGEWAY OF MENSTRUATION = PASSAGEWAY OF FETUS

= ORGAN OF COPULATION
= SEMEN DEPOSITORY

** DODERLIENS BACILLUS MAINTAINS THE NORMAL FLORA OF THE VAGINA, WHICH MAKES THE pH OF VAGINA ACIDIC, DETRIMENTAL TO THE GROWTH OF PATHOLOGIC BACTERIA.

VAGINA
Functions:
Organ of copulation Discharges menstrual flow Birth canal

pH 4-5 : acidic

 RUGAE TRANSVERSE FOLDS OF SKIN IN THE VAGINAL WALL THAT IS ABSENT IN CHILDHOOD, APPEAR AFTER PUBERTY & DISAPPEARS AT MENOPAUSE. FORNIX-FORNICES= THE CERVIX PROJECTS TO THE VAGINA FORMING FOUR RECESSES OR DEPRESSION AROUND ITS UPPER PORTION CALLED FORNICES: ANTERIOR FORNIX, LATERAL FORNICES, POSTERIOR FORNIX.

VAGINITIS
inflammation of the vagina characterized by an increased vaginal discharge containing numerous WBCs Causes: Douches Antibiotics Hormones Contraceptives (oral and topical) Change in sexual partners

Signs and Symptoms: Itching Burning Pain Erythema Edema

BARTHOLINS CYST
occlusion of a duct with mucus retention resulting in a nontender mass approx. 1-4cm in size Causes if the duct becomes blocked for any reason: infection, injury or chronic inflammation Very rarely, caused by cancer Unknown (many cases)

Causative organisms: Staphylococcus aureus (others: S. fecalis, E. coli, N. gonorrhea, ) Symptoms: Bartholyns Cyst (asymptomatic) Bartholins Abscess - pain or tenderness, dyspareunia Diagnosis clinical Management incision and drainage marsupialization entire abscess is incised and sewn open broad spectrum antibiotic

Nursing interventions Teach the importance of completing the course of antibiotic Teach the importance of good hygiene Sitz bath for both pain relief and to decrease healing time

CONGENITAL ABSENCE OF THE VAGINA

The usual lesion consists:
absence of the middle and upper vagina, total absence or a rudiment in the location of the uterus, an absence or one or both Fallopian tubes.

The vagina may be totally absent, or represented by a rudimentary pouch of up to one half to three quarters of an inch deep.

Vaginal agenesis

CONGENITAL ABSENCE OF THE VAGINA

is a rare anomaly, 1: 5000 birth Known also as aplasia or dysplasia of the Mllerian (paramesonephric) ducts. Referred to as ROKITANSKY-KUSTER-HAUSER SYNDROME The external genitalia and vestibule, deriving from the urogenital sinus, are normal. The sex chromatin pattern is female. endocrine system is not affected. Ovarian function is normal

CONGENITAL ABSENCE OF THE VAGINA

Cause :
UNKNOWN no known gene is linked to this condition.

MANIFESTATION
Primary amenorrhea and cyclic abdominal pain Infertility Inability to have intercourse Associated with renal malformation
There are associated renal and vertebral anomalies (e.g., fused or solitary pelvic kidney, spina bifida).

PHYSICAL FINDING
Normal secondary female sexual characteristics are present after puberty. Height is normal. Speculum examination of the vagina may be impossible or difficult because of the degree of vaginal agenesis. The vulva, labia majora, labia minora, and clitoris are normal. A palpable sling of tissue may be present at the level of the peritoneal reflection.

Diagnostic:
Imaging studies
UTZ MRI Laparoscopy provides only indirect assessment of uterine cavitation. Laparoscopy is the preferred procedure when uterine remnants or endometriosis cause cyclic pelvic pain requiring excision. Pyelography: Perform intravenous pyelography to assess renal structure. Radiography: Perform spinal radiography to exclude vertebral anomalies

Management
Treatment : Surgical Vaginal reconstruction modified McIndoe vaginoplasty Prognosis: The patient may have normal sexual functioning after surgical reconstruction. Surgical reconstruction does not establish the ability to conceive through natural means.

Modified McIndoe Vaginoplasty

** DODERLIENS BACILLUS MAINTAINS THE NORMAL FLORA OF THE VAGINA, WHICH MAKES THE pH OF VAGINA ACIDIC, DETRIMENTAL TO THE GROWTH OF PATHOLOGIC BACTERIA.
B. UTERUS = HOLLOW, MUSCULAR PEAR SHAPED ORGAN LOCATED IN THE PELVIS, WEIGHING 5060 g IN A NON-PREGNAT WOMAN. HELD IN PLACE BY BROAD LIGAMENTS. ABUNDANT BLOOD SUPPLY COMES FROM UTERINE AND OVARIAN ARTERIES.

- DURING PUBERTY, IT INCREASES IN SIZE & REACHES ITS MAXIMUM SIZE AT 17 YRS
- FUNCTONS:

a. ORGAN OF IMPLANTATION ( NIDATION)

AND MENSTRUATION

b. RECEIVES THE OVA FROM THE FALLOPIAN TUBE

c. FURNISHES PROTECTION FOR A GROWING FETUS

DIVISIONS OF THE UTERUS

1.CERVIX = LOWER PORTION CALLED THE NECK a. EXTERNAL CERVICAL OS = DISTAL OPENING TO THE VAGINA b. CERVICAL CANAL = THE CAVITY c. INTERNAL CERVICAL OS = OPENING TO THE UTERUS 2. FUNDUS = UPPERMOST CONVEX PORTION AND CAN BE PALPATED TO DETERMINE UTERINE GROWTH DURING PREGNANCY , TO ASSESS UTERINE CONTRACTIONS DURING LABOR,& INVOLUTION DURING THE POSTPARTUM PERIOD

= MOST VASCULAR PORTION

= NORMAL IMPLANTATION SITE

3. CORPUS BODY OF THE UTERUS WHICH MAKES UP 2/3 OF THE SAID ORGAN. HOUSES THE FETUS DURING PREGNANCY 4.CORNUA THE UPPER PORTION WHERE THE FALLOPIAN TUBES ARE ATTACHED.

LAYERS:
1.PERIMETRIUM = OUTERMOST LAYER, IT IS ATTACHED TO THE BROAD LIGAMENTS & OFFER ADDED SUPPORT TO THE UTERUS

= MOST VASCULAR PORTION

= NORMAL IMPLANTATION SITE

3. CORPUS BODY OF THE UTERUS WHICH MAKES UP 2/3 OF THE SAID ORGAN. HOUSES THE FETUS DURING PREGNANCY 4.CORNUA THE UPPER PORTION WHERE THE FALLOPIAN TUBES ARE ATTACHED.

LAYERS:
1.PERIMETRIUM = OUTERMOST LAYER, IT IS ATTACHED TO THE BROAD LIGAMENTS & OFFER ADDED SUPPORT TO THE UTERUS

2. MYOMETRIUM
= MIDDLE LAYER , EXPELS FETUS DURING BIRTH PROCESS THEN CONTRACTS AROUND BLOOD VESSELS TO PREVENT HEMORRHAGE (OXYTOCIN SITE) 3. ENDOMETRIUM

= INNERMOST LAYER; THIS LAYER UNDERGO CHANGES IN RESPONSE TO THE HORMONES AT VARIOUS PHASES OF THE MENSTRUAL CYCLE & DURING PREGNANCY; IT CONSISTS OF TWO LAYERS:

Endometriosis
Endometrial tissue outside the uterine cavity.
when cells from the uterus, called endometrial cells, are found outside the uterus. The cells attach to other organs

Pelvis most common location Bleeding results to inflammation, scarring of peritoneum and adhesions Cause unknown Common in 20-45 yrs old

Common Sites 0f Endometriosis Formation

Endometriosis

Management
OCP-combination contraceptives to induce amenorrhea Analgesics NSAIDS Danazol antiprogesterone; suppresses GnRH, low estrogen and high androgens to suppress ovulation, promote amenorrhea and decrease endometrial support GnRH agonists ie Leuprolide suppress the menstrual cycle through estrogen antagonism Progestins ie Medroxyprogesterone antiendometrial effect

Uterine malformation Types classification:

Class I: Mullerian agenesis (absent uterus).
Class II: Unicornuate uterus (a one-sided uterus). Class III: Uterus didelphys, (double uterus). Class IV: Bicornuate uterus (uterus with two horns).

 Class V: Septated uterus (uterine septum or partition). Class VI: DES uterus.
The uterine cavity has a "T-shape" as a result of fetal exposure to diethylstilbestrol.

unicornuate uterus
(a womb with one 'horn') happens when the tissue that forms the womb does not develop properly. very rare condition. A unicornuate uterus is just half the size of a normal UTERUS and the woman has only one fallopian tube. However, she usually has two ovaries

Unicornuate uterus
is smaller than a typical uterus and usually has only one functioning fallopian tube. The other side of the uterus may have what is called a rudimentary horn.

Unicornuate uterus
Most of the time it does not cause any gynecologic or obstetric problem

DIAGNOSTIC
Imaging studies
Hysterosalpingography (HSG), performed under fluoroscopy, allows evaluation of the uterine cavity and tubal patency Hysteroscopy three-dimensional ultrasound laparoscopy might also be used to confirm the diagnosis.

RISK
PRETERM LABOR-is thought to be because of space restrictions; because a unicornuate uterus is smaller than a typical uterus, the growth of the baby might trigger early labor. MISCARRIAGE-due to abnormalities in the blood supply of the unicornuate uterus that might interfere with the functioning of the placenta ECTOPIC PREGNANCY miscarriage in 37% preterm birth in 16%, term birth in only 45%.

MANAGEMENT
The resection of the obstructed hemi-uterus can be performed laparoscopically. Nursing management:
Informed consent Explain the procedure Monitor vital sign Emotional support

BICORNUATE UTERUS
a type of congenital uterine malformation (mllerian duct abnormality). uterus is heart-shaped with two joined cavities whereas a typical uterus has a single cavity.

Cause
This can happen to women whose mothers took a medication called DES during pregnancy, it can happen for unknown reasons.

Diagnosing Bicornuate
hysterosalpingogram (HSG) hysteroscopy but diagnosis should be confirmed with a three-dimensional ultrasound or laparoscopy.

Double uterus
Definition In a female fetus, the uterus starts out as two small tubes. As the fetus develops, the tubes normally join to create one larger, hollow organ the uterus. Sometimes, however, the tubes don't join completely. Instead, each one develops into a separate cavity. This condition is called double uterus (uterus didelphys).

Double uterus
Each cavity in a double uterus often leads to its own cervix. Some women with a double uterus also have a duplicate or divided vagina. Double uterus is rare and sometimes not even diagnosed. occurs in 2 %t to 4 % of women who have normal pregnancies. The percentage may be higher in women with a history of miscarriage or premature birth. Treatment is needed only if a double uterus causes symptoms or complications, such as pelvic pain or repeated miscarriages.

Symptoms
Some women have a double uterus and never realize it even during pregnancy and childbirth. Possible signs and symptoms may include:
A mass in the pelvis Unusual pain before or during a menstrual period Abnormal bleeding during a period, such as blood flow despite the use of a tampon

Causes
Unknown . The condition is associated with kidney abnormalities, which suggests that something may influence the development of these related tubes before birth.

C. FALLOPIAN TUBES / OVIDUCTS / UTERINE TUBES

= TWO SLENDER MUSCULAR TUBES WHICH ARISES FROM EACH OF THE UPPER CORNER OF THE UTERINE BODY AND EXTEND OUTWARD. PROVIDES A PLACE FOR FERTILIZATION ( CONCEPTION, FECUNDATION, IMPREGNATION) OF OVA BY THE SPERM.

PARTS:
1.INTERSTITIAL =( 1cm) LIES WITHIN THE UTERINE WALL. IT HAS THE SMALLEST LUMEN. 2. ISTHMUS =( 2cm) PORTION CUT OR SEALED DURING TUBAL LIGATION.( BTL)

3. AMPULLA =( 5cm) LONGEST PORTION, EXACT SITE OF FERTILIZATION ( DISTAL 3RD, OUTER 3RD) 4. INFUNDIBULUM =MOST DISTAL PORTION; RIM OF THE FUNNEL IS COVERED BY FIMBRAE THAT HELPS GUIDE THE OVA INTO THE FALLOPIAN TUBE.

 FUNCTION:
TRANSPORT OVUM FROM OVARY TO THE UTERUS SITE OF FERTILIZATION

Pelvic Inflammatory Disease: Salphingitis

Inflammatory condition of the pelvic cavity that may involve the ovaries, fallopian tubes, vascular system or pelvic peritoneum. Caused by microorganims colonizing endocervix ascending to endometrium and fallopian tubes Major cause of female infertility

Risk Factors:
Multiple sexual partners Hx of PID Early onset of sexual activity IUD

 Manifestations:
Pelvic pain ( sharp & cramping); Fever; nausea, malaise; severe lower abdominal pain; Purulent foul smelling vaginal discharge; Menorrhagia; tenderness in both lower abdominal quadrants; dyspareunia

Diagnostics & Laboratory Tests:

Hx & PE; CBC; vaginal & endocervical culture; VDRL; Endometrial biopsy: UTZ;

Management:
Antibiotics; IV fluids/ inc. oral fluid; pain meds; Remove IUD; Evaluation of sexual partners; application of heat to relieve pain; surgical excision of abscess if present

Toxic Shock syndrome ( TSS) Reproductive age, near menses or postpartum period D/t toxins released by S. Aureus R/t use of tampons (Mg absorbing fibers of tampons cause dec Mg levels contributing to toxin production by bacteria in the lower reproductive tract), cervical cap or diaphragm
Manifestations: sudden high fever, headache, vomiting, rash on trunk, desquamation of skin, hypotension, dizziness, diarrhea, inflamed mucous membranes

Management: IV fluids Antibiotics Client education: 1.change tampons 3-6 hours 2.avoid tampons 6-8 wks after childbirth 3.do not leave diaphragms>48 hours

BARRIER METHODS

DIAPHRAGM
-mechanically blocks sperm from entering the cervix -soft latex dome supported by a metal rim -can be inserted 2 hours before intercourse; removed at least 6 hours after coitus or within 24 hours - must be refitted if the person gained 10 or more lbs or has given birth -size must fit the individual - initially fitted by a doctor -washable, may be used for 2-3 years

Contraindications: Allergy to latex History of TSS Pelvic pain PID Tight introitus

Client Instructions: A woman should be fitted by an obstetrician during the first if use & refitted after every delivery, abortion, & weight loss of at least 10 lbs. The largest size that fits the woman is chosen. Normally becomes brownish with use. Before inserting into the vagina, it should be inspected for tears & holes by holding it against the light Spermicide gel is applied at its rim before insertion

 Diaphragm can be inserted 2 hours before coitus but must be left for 6 hours after intercourse. After use, diaphragm is washed with soap & water, dried with a towel & can be dusted with cornstarch. Do not use talcum powder, perfumed substances & petrolatum jelly because they may damage the diaphragm & irritate the vagina. It should be stored in a plastic container in a cool dry place. Can last 2-3 years

 If there is difficulty in removing the diaphragm after intercourse, bear down to bring it forward where you can reach it with your fingers. Do not douche while it s inside the vagina Prevent TSS by:
Washing hands before insertion or removal Do not leave more than 24 hours in the vagina Never use during menses Wait 12 weeks after delivery before using the contraceptive Remove right away if there ssx of TSS & consult physician

D. OVARIES = ALMOND SHAPED ORGANS LOCATED ON EITHER SIDE OF THE UTERUS. BEFORE PUBERTY, THE OVARIES ARE SMOOTH, FLAT & OVOID ORGANS. AFTER OVULATIONS, THEY ASSUME A NODULAR & PITTED APPEARANCE. FUNCTIONS: = RESPONSIBLE FOR THE PRODUCTION, MATURATION AND DISCHARGE OF OVA AND SECRETION OF ESTROGEN AND PROGESTERONE = ORGAN OF OVULATION

OVARIES
Function
Oogenesis Ovulation Hormone production estrogen & progesterone

LAYERS OF THE OVARY:

1.TUNICA ALBUGINEA - THE OUTERMOST PROTECTIVE LAYER SURROUNDED BY A SINGLE LAYER OF CUBOIDAL EPITHELIUM.

2. CORTEX
- THE FUNCTIONAL LAYER WHICH IS
THE SITE OF OVUM FORMATION & MATURATION. IT CONTAINS THE PRIMORDIAL FOLLICLES, GRAAFIAN

FOLLICLES, CORPUS LUTEUM & CORPUS ALBICANS. - two months intrauterine = 600,000 oogonia - 5 months intrauterine = 6,800,000 - at birth = 2 million oocytes - prepuberty / childhood = 300,000 to 400,000

- 36 years old = 30,000 to 40,000

- menopause = absent

3. MEDULLA - LAYER WHICH CONTAINS THE

BLOOD VESSELS, LYMPHATICS, NERVES & MUSCLE FIBERS.

THE MAMMARY GLANDS

THE FEMALE BREASTS ARE ACCESSORY ORGANS OF REPRODUCTION MEANT TO PROVIDE THE INFANT WITH THE MOST IDEAL NOURISHMENT AFTER BIRTH. STRUCTURES:

LOBES =EACH BREAST CONSISTS OF 15-20 LOBES FOUND IN EACH BREAST WHICH ARE SUBDIVIDED INTO LOBULES LOBULES COMPOSED OF CLUSTERS OF ACINAR CELLS ( RESPONSIBLE FOR MILK PRODUCTION)

3.ACINAR CELLS MILK SECRETING CELLS THAT IS STIMULATED BY PROLACTIN 4.LACTIFEROUS DUCTS = MILK RESERVOIR WHICH OPEN TO THE NIPPLE.

5.AREOLA = DARK PIGMENTED PART AROUND THE NIPPLE

6. MONTGOMERY TUBERCLE = SECRETES FATTY SUBSTANCE TO LUBRICATE NIPPLES 7. NIPPLE = ELEVATED PART OF THE BREASTS CONTAINING 15-20 OPENINGS FROM THE LACTIFEROUS DUCTS 8. COOPERS LIGAMENT = PROVIDES SUPPORT TO THE MAMMARY GLAND

PHYSIOLOGY OF MILK PRODUCTION

** THE PRODUCTION OF BREAST MILK IS NOT ACHIEVED DURING PREGNACY BECAUSE OF THE PREDOMINANCE OF ESTROGEN & PROGESTERONE. ** IMMEDIATELY AFTER THE DELIVERY OF THE PLACENTA, THERE IS MARKED DECREASE OF BOTH ESTROGEN & PROGESTERONE W/C SERVES AS A STIMULUS FOR THE APG TO PRODUCE PROLACTIN. ** PROLACTIN ACTS ON THE ACINI CELLS TO STIMULATE PRODUCTION OF MILK & ARE THEN STORED IN THE LACTIFEROUS DUCTS.

** AS THE INFANT SUCKS, THE PPG IS STIMULATED TO RELEASE THE HORMONE OXYTOCIN CAUSING THE COLLECTING SINUSES OF THE MAMMARY GLANDS TO CONTRACT, FORCING MILK FORWARD THROUGH THE NIPPLES CALLED LET DOWN REFLEX OR MILK EJECTION REFLEX.

BREAST DISORDERS
Breast CA Benign Breast CA

Fibrocystic breast disease

Most common benign condition of the breast 20-50 yo D/t imbalance between hormones Rare in postmenopausal women not taking HRT Not risk for Ca except if px has (+) family hx and w/ atypical cellular changes on biopsy S/sx: bilateral cyclic pain, tenderness, nipple discharge Dx: mammography, sonography, FNA Mgmt: restrict Na, mild diuretic, Danazol (hormone inhibitor), Bromocriptine and Tamoxifen to decrease symptoms

Fibroadenoma
2nd most common Teens, early 30s Not associated w/ breast Ca

S/sx: freely movable, solid, well defined, sharply delineated, rounded w/ a rubbery texture
Dx: USG, FNA Mgmt: surgery of enlarged

BREAST CANCER
** PRESENCE OF MALIGNANT TUMORS USUALLY IN THE UPPER OUTER QUADRANT OF THE BREAST. IT IS ASSOCIATED WITH NULLIPARITY OR HAVING THE FIRST CHILD AFTER AGE 35. 1.MOST COMMON NEOPLASM IN WOMEN

2. LEADING CAUSE OF DEATH IN WOMEN AGE 40 above

MEDICAL MANAGEMENT: 1.USUALLY SURGICAL EXCISION; OPTIONS ARE SIMPLE LUMPECTOMY, SIMPLE MASTECTOMY, MODIFIED RADICAL MASTECTOMY AND RADICAL MASTECTOMY

2.TREATMENT WITH CHEMOTHERAPY, RADIATION AND HORMONE THERAPY

** PARTIAL MASTECTOMY = (LUMPECTOMY) REMOVAL OF LUMP & SURROUNDING BREAST TISSUE

**SIMPLE MASTECTOMY = REMOVAL OF THE BREAST ** RADICAL MASTECTOMY = REMOVAL OF THE BREAST, PECTORAL MUSCLES, PECTORAL FASCIA & NODES (PECTORAL, SUBCLAVICULAR, APICAL AND AXILLARY) ** MODIFIED RADICAL MASTECTOMY = RADICAL MASTECTOMY BUT PECTORAL MUSCLES ARE NOT REMOVED

MOST COMMON SITE OF METASTASIS:

** BONE, BONE MARROW, SOFT TISSUE, LUNGS, LIVER AND BRAIN.

C. ASSESSMENT FINDINGS:
1.PALPATION OF LUMP (UPPER OUTER QUADRANT MOST FREQUENT SITE) USUALLY FIRST SYMPTOM 2. SKIN OF BREAST DIMPLED

3. NIPPLE DISCHARGE
4. ASSYMETRY OF BREAST

5. SURGICAL BIOPSY PROVIDES DEFINITE DIAGNOSIS

**BREAST BIOPSY** 1. EXCISION =REMOVAL OF MASS FOR CYTOLOGIC STUDIES 2. INCISION= REMOVAL OF TISSUE FROM MASS OF CYTOLOGIC STUDIES 3. NEEDLE= (ASPIRATION) = REMOVAL OF TISSUE OR FLUID FROM MASS THROUGH A NEEDLE FOR CYTOLOGIC STUDY

LABORATORY DATA:
- MAMMOGRAPHY REVEALS THE PRESENCE OF NON-PALPABLE LESION.

- BASELINE MAMMOGRAPHY SHOULD BE MADE BETWEEN AGES 35-40.

NURSING INTERVENTIONS:
1. PROVIDE ROUTINE PRE-OP & POST-OP CARE. 2. ELEVATE CLIENTS ARM ON OPERATIVE SIDE ON PILLOWS TO MINIMIZE EDEMA. 3. DO NOT USE ARM ON AFFECTED SIDE FOR BLOOD PRESSURE MEASUREMENTS, IVS OR INJECTIONS 4. TURN ONLY TO BACK & UNAFFECTED SIDE

5. MONITOR CLIENT FOR BLEEDING ( CHECK UNDER AFFECTED ARM)

Risk Factors: Age, female, family hx, HRT > 5 yrs, overweight after menopause, alcohol, no history of pregnancy or 1st pregnancy after age 30, never breastfeeding, early menarche, late menopause, radiation, upper socioeconomic areas, geographic location Dx: mammography, FNA, USG, MRI May be managed by surgery, radiation therapy, and/or chemotherapy Tamoxifen (anti-estrogen) Emotional responses

Nursing care in addition to routine postop care: Inspect dressing and incision for bleeding To prevent lymphedema (pooling of lymph circulation in involved arm), elevate it on a pillow, turn patient to back and unaffected side; avoid constricting clothing and using the arm for blood pressure measurement, IVs, injections To prevent muscle contractures, encourage an exercise program with gradual progression from those that do not stress the incision to adduction and external rotation Promote acceptance of new body image by providing emotional support

What is Dyspareunia?
Vaginal pain after sexual intercourse. Painful sexual intercourse.

CAUSES Dyspareunia
Poor vaginal lubrication Reduced libido Reduced estrogen Vaginal dryness Inadequate foreplay Menopause Perimenopause Lactation - causes vaginal dryness

Dyspareunia
Post-childbirth
Episiotomy - if performed for childbirth

Vaginal infection Cystitis Urethritis Vaginal infection Vulva infection Atrophic vaginitis Vaginal changes from childbirth

CAUSES Dyspareunia
Narrow vaginal
Hymen

Psychological disorders
Anxiety

Vaginismus Endometriosis Hemorrhoids

CAUSES Dyspareunia
Pelvic infection
Pelvic inflammatory disease

Genital tract tumor

Vaginal tumors Vaginal surgery

Pelvic disorders Sexual organ disorders Some causes of deep penetration intercourse pain in women include:
Pelvic inflammatory disease Pelvic tumor

MANAGEMENT Dyspareunia
History and physical examination with pelvic and rectal exams Timing: Onset (e.g., upon entry, after intercourse), duration, persistence after intercourse, prior occurrence(s) Associations: Symptoms may occur with all vaginal or vulvar contact, with intercourse only, with exams only, with masturbation, or with memories or recollections of prior occurrences or traumatic experiences Alleviating and aggregating factors during intercourse Qualifiers: Burning, sharp, dull, aching, throbbing, stabbing Include complete psychiatric history and exam

Vaginismus:
Vaginal entrance muscle spasms triggered by sex Involuntary contraction of muscle at the outlet of the vagina when coitus is attempted prohibiting penile penetration or during sexual intercourse.

CAUSES
Fear of sex Unpleasant sexual experience Negative attitude to sex

TREATMENT
PSYCHOLOGICAL COUNSELLING

Prognosis of Vaginismus
Most women recover to normal sex life and motherhood with treatment.

FRIGIDITY
Loss of libido Sexual aversion disorder

Signs / symptoms
Loss of female libido Lack of enjoyment of intercourse Painful intercourse Vaginal dryness

CAUSES
1. Organic 2.Functional

Organic
Malformation
Imperforate hymen Vaginal stenosis Hermaphroditism Retroverted uterus Turner syndrome-the normal XX sex chromosomes for a female, only one X chromosome is present(45X0) . female sexual characteristics are present but generally underdeveloped.

Organic
Inflammation
PID Cystitis Anal fissure Vaginitis Salphangitis endometeritis

Organic
Trauma
Enlarge male organ Masturbation Sexual molestation/raped

Functional Cause
Psychological cause
Fear or hostility regarding intercourse Anxiety : previous rape Marital difficulties

Diagnostics
Pelvic & rectal exam Chromosomal analysis if indicated Hormonal analysis
FSH Estradiol

UTZ/ vaginal smear & culture Gynecologic exam

Treatment
Treat the cause Estrogen therapy as prescribed Psychiatrist Emotional support

MALE REPRODUCTIVE SYSTEM: ANDROLOGY

B.

Penis: the male organ of copulation; a cylindrical shaft consisting of: a. corpora cavernosa -two lateral columns of erectile tissue b. corpus spongiosum - encases the urethra Parts: 1.The glans penis, a cone-shaped expansion of the corpus spongiosum that is highly sensitive in males. 2. Shaft or body 3. Prepuce or Foreskin retractable skin covering the glans & removed during circumcision. Unretractable or tight foreskin is called PHIMOSIS. -Erection is stimulated by parasympathetic nerve C. Scrotum: a pouch hanging below the penis that contains the testes.

INTERNAL STRUCTURES: A.TESTES = TWO OVOID SHAPED BODY THAT LIE INSIDE THE SCROTUM

= ENCASED BY A PROTECTIVE WHITE FIBROUS CAPSULE AND COMPRISES A NUMBER OF LOBULES

= EACH LOBULE CONTAINS INTERSTITIAL

CELLS ( LEYDIGS CELLS) AND SEMINIFEROUS TUBULES

= SEMINIFEROUS TUBULES PRODUCE SPERMATOZOA = LEYDIGS CELLS PRODUCE THE HORMONE TESTOSTERONE

FUNCTIONS OF THE TESTES:

1. SPERMATOGENESIS = PROCESS BY WHICH THE SPERMATOCYTES ARE DEVELOPED INTO MATURE SPERMATOZOA 2. HORMONE PRODUCTION a. TESTOSTERONE = AN ANDROGEN OR MUSCULINIZING HORMONE RESPONSIBLE FOR ** GROWTH & DEVELOPMENT OF SECONDARY SEX CHARACTERISTICS

b. FSH = FOLLICLE STIMULATING HORMONE

= CAUSES RAPID SPERM PRODUCTION BY THE TUBULE

c. ICSH INTERSTITIAL CELL STIMULATING HORMONE

= STIMULATES LEYDIGS CELLS TO INCREASE TESTOSTERONE PRODUCTION

Spermatogenesis
Testes Contain Leydig cells produces testosterone
ALERT: it takes 64 days for sperm to reach maturity

Testosterone
Stimulates APG secrete FSH & LH

stimulates seminiferous tubules to produce spermatozoa

Sperm Pathway
Testes ---produces sperms Epididymis conducts sperm to Vas deferens

Seminal vesicles ( secretion of fructose & protein)

Ejaculatory duct
Urethra ( 8 inches) ( cowpers gland secretes alkaline fluid)

OUT

Male

MALE REPRODUCTIVE SYSTEM:

B. Internal Structures
1. Epididymis: serves as reservoir for sperm storage and maturation. Approximately 20 ft. it takes 12-20 days for the sperm to travel the length of Epididymis. A total of 64 days before they reach maturity. (Treatment= 2 months). Aspermia (absence of sperm) Oligospermia- if < 20 million sperm/ ml 2. Vas deferens: a duct extending from epididymis to the ejaculatory duct and seminal vesicle, providing a passageway for sperm. Varicocele- varicosity of internal spermatic cord Vasectomy (male birth control) 3. Seminal vesicle: are two convoluted pouches that lie along the lower portion of the bladder and empty into the urethra by the way of ejaculatory ducts

MALE REPRODUCTIVE SYSTEM: 4. Ejaculatory duct: the canal formed by the union of the vas deferens and the excretory duct of the seminal vesicle, which enters the urethra at the prostate gland. 5. Prostate Gland: located just below the urinary bladder. Secretes alkaline and most of the seminal fluid. 6. Bulbourethral glands or Cowpers Gland: adds alkaline fluid to the semen. Counterpart of the Bartholins glands in females. 7. Urethra: the passageway for both urine and semen, extending from the bladder to the urethral meatus. (8 inches in long)

SEMINAL FLUID / SEMEN:

= A GRAYISH WHITISH SUBSTANCE CONTAINING SPERMATOZOA AND FRUCTOSE RICH SUBSTANCES. = AT THE TIME OF EJACULATION, APPROXIMATELY 3-5 ML OF SEMEN IS SECRETED WITH ABOUT 100 MILLION SPERMATOZOA PER ML, OR ABOUT 250-500 MILLION SPERMATOZOA AT EACH EJACULATION. IF THE SPERM COUNT DROPS TO LESS THAN 20 MILLION PER ML OF SEMEN, THE RATE IS CONSIDERED INFERTILE.

SEXUAL DYSFUNCTION IN MALE

Erectile dysfunction Impotence

Erectile dysfunction (Impotence)

Inability of the man to produce or maintain erection , long enough for vaginal penetration or partner satisfaction. Formerly called impotence

Causes
Physical cause Common causes of erectile dysfunction include:
Heart disease Clogged blood vessels (atherosclerosis) High blood pressure Diabetes Obesity Metabolic syndrome

Causes
Other causes of erectile dysfunction include:
Certain prescription medications -antidepressants, antihistamines and medications to treat high blood pressure, pain and prostate cancer Tobacco use Alcoholism and other forms of drug abuse Treatments for prostate cancer Parkinson's disease Multiple sclerosis Hormonal disorders such as low testosterone (hypogonadism) Surgeries or injuries that affect the pelvic area or spinal cord

 Psychological causes of erectile dysfunction The brain plays a key role in triggering the series of physical events that cause an erection, beginning with feelings of sexual excitement. A number of things can interfere with sexual feelings and lead to or worsen erectile dysfunction. These can include: Depression Anxiety Stress Fatigue Poor communication or conflict with your partner

 Ultrasound. This test can check blood flow to your penis. Neurological evaluation. Dynamic infusion cavernosometry and cavernosography (DICC).
This procedure involves injecting a dye into penile blood vessels to permit view any possible abnormalities in blood pressure and flow into and out of your penis. It's generally done with local anesthesia by a urologist who specializes in erectile dysfunction.

Nocturnal tumescence test.

A simple test that involves wrapping a special perforated tape around the penis before going to sleep can confirm whether you have erections while you're sleeping. If the tape is separated in the morning, your penis was erect at some time during the night. Tests of this type confirm that there is not a physical abnormality causing erectile dysfunction, and that the cause is likely psychological.

 Oral medications Oral medications available to treat ED include:

Sildenafil (Viagra) Tadalafil (Cialis) Vardenafil (Levitra)

ACTION :
Chemically known as phosphodiesterase inhibitors, these drugs enhance the effects of nitric oxide, a chemical that relaxes muscles in the penis. This increases the amount of blood flow and allows a natural sequence to occur an erection in response to sexual stimulation.

 Hormone replacement therapy For the small number of men who have testosterone deficiency, testosterone replacement therapy may be an option. Penis pumps This treatment involves the use of a hollow tube with a handpowered or battery-powered pump. The tube is placed over the penis, pump is used to suck out the air. This creates a vacuum that pulls blood into the penis. Once you achieve an adequate erection, slip a tension ring around the base of the penis to maintain the erection. then remove the vacuum device. The erection typically lasts long enough for a couple to have sex. remove the tension ring after intercourse. Vascular surgery This treatment is usually reserved for men whose blood flow has been blocked by an injury to the penis or pelvic area. The goal of this treatment is to correct a blockage of blood flow to the penis so that erections can occur naturally. But the longterm success of this surgery is unclear.

 Penile implants The inflatable device allows to control when and how long you have an erection, These implants consist of either an inflatable device or semirigid rods made from silicone or polyurethane. This treatment is often expensive and is usually not recommended until other methods have been considered or tried first. As with any surgery, there is a small risk of complications such as infection. Psychological counseling and sex therapy
Stress, anxiety or depression is the cause of erectile dysfunction Counseling can help, especially when your partner participates.

Nursing care
Patient education
Limit or avoid the use of alcohol. Avoid illegal drugs such as marijuana. Stop smoking. Exercise regularly. Reduce stress. Get enough sleep. Get help for anxiety or depression. advised regular checkups and medical screening tests.

Communicate with patient and partner openly

MENOPAUSE = PERMANENT CESSATION OF MENSTRUAL CYCLES THAT OCCURS BETWEEN 45 & 55 Y/O; ave: 50y/o = THE POINT AT WHICH NO FUNCTIONING OOCYTES REMAIN IN THE OVARIES

S/SX OF MENOPAUSE: 1.HOT FLASHES SENSATION OF HEAT THAT BEGINS IN THE FACE TO THE CHEST & PROFUSE PERSPIRATION. 2. LOSS OF BREAST MASS & FIRMNESS, ATROPHY OF REPRODUCTIVE ORGANS. 3. DYSPAREUNIA ( PAINFUL INTERCOURSE) DUE TO DECREASED VAGINAL LUBRICATION. 4. OSTEOPOROSIS - ESTROGEN PROMOTES CALCIUM DEPOSITION IN THE BODY. A FALL IN ESTROGEN LEVELS WILL LIBERATE CALCIUM FROM THE BONES MAKING THEM BRITTLE

MX:

1. ESTROGEN REPLACEMENT THERAPY ( HRT; ERT)

2. CALCIUM ( 1g/DAY AT HS) & VIT. D SUPPLEMENTATION 3. LIBERAL FLUID INTAKE TO DILUTE URINE AS MORE CALCIUM IS LIBERATED FROM THE BONES & COULD CAUSE RENAL CALCULI. 4. WEIGHT BEARING EXERCISES MX OF HOT FLASHES:

1. DRESS IN LAYERED LOOK, REMOVE OUTER CLOTHING DURING ATTACKS.

2. AVOID HOT ENVIRONMENT

3. AVOID EMOTIONAL STRESS 4. AVOID FOODS THAT COULD TRIGGER HOT FLUSHES: SPICY FOODS, COFFEE, TEA, ALCOHOL 5.USE COOLING TECHNIQUES: FANS, SHOWERS, ICE CUBES NURSING CARE:

1.ENCOURAGE WOMAN TO ENGAGE IN REGULAR EXERCISE PROGRAM TO MAINTAIN MUSCLE TONE

2. EMPHASIZE ADEQUATE INTAKE OF CALCIUM 3. VIT D FOR BETTER CALCIUM ABSORPTION. 4.INSTRUCT ON PROPER USE OF WATER SOLUBLE

VAGINAL LUBRICANT FOR PAINFUL INTERCOURSE.

5. INSTRUCT TO AVOID SMOKING & ALCOHOL

6. REGULAR PHYSICAL EXAMINATION.

SEXUALLY TRANSMITTED DISEASES

Trichomoniasis Chlamydia Gonorrhea Syphilis Herpes simplex Condylomata acuminatum Human Immunodefiency Virus (HIV) and AIDS

TRICHOMONIASIS
protozoan infection: Trichomona vaginalis Signs and Symptoms Frothy yellow-green malodorous vaginal discharge strawberry cervix Vaginal irritation & inflammation Dyspareunia Dysuria Vulvar itching Among males: usually asymptomatic

Diagnosis microscopic exam of vaginal discharge -positive motile flagellated protozoa in a saline wet mount elevated vaginal pH 5.5+ (alkaline) Management Sexual partner should receive oral treatment. Metronidazole (Flagyl) 500 mg BID for 7 days or a single 2 g dose (contraindicated during pregnancy)

Home Remedy Acidic vaginal douche : 1 tablespoon vinegar with 1 liter water to counteract the alkaline environment of the vagina that favors the growth of Trichomonas vaginalis Nursing interventions Include sexual partner in treatment. Advise use of condom during intercourse Nursing alerts: - Concurrent alcohol ingestion with Metronidazole causes severe GI symptoms (Antabuse-like reaction) - Metronidazole is associated with preterm labor, premature rupture of membranes and postcesarean infection

CHLAMYDIA
most common cause of mucopurulent cervicitis most common bacterial STD in women caused by gram (-) bacterium Chlamydia trachomatis Vertical transmission to newborns may result in conjunctivitis and otitis media Tends to coincide with gonorrhea infection IP: 2-10 days Risk Factors Sexual activity < 20 years Multiple sexual partners Lower socioeconomic status (+) others STDs

Signs and symptoms May be asymptomatic Gray white/ yellowish vaginal discharge Burning and itchiness Bleeding between periods Mucopurulent cervicitis Painful and frequent urination

Diagnosis (+) culture/ antigen detection test on cervical smear Polymerase chain reaction (PCR)

Management Doxycycline 100 mg PO BID for 7 days (causes fetal long bone deformity if used in pregnancy) Azithromycin (Zithromax) 1 g PO in a single dose Erythromycin 500 mg QID for pregnant patient Patient may also be treated for gonorrhea with a single IM shot of Ceftriaxone 250 mg Infant treated with Erythromycin ophthalmic ointment Nursing interventions Client teaching: Teach the importance of completing the course of antibiotic Use condom during sex Sexual partner should receive treatment

Complications Pelvic inflammatory disease (PID) Ectopic pregnancy Fetus transmittal (vaginal birth); may cause conjunctivitis (also associated with premature rupture of membranes, preterm labor and endometriosis, low birth weight and perinatal mortality due to placental transmission)

GONORRHEA
Morning drop, Clap, Jack Sexually transmitted disease caused by gram (-) Neisseria gonorrhea, which causes inflammation of the mucus membrane of the genito urinary tract IP: 3-7 days

Signs and Symptoms Females: may be asymptomatic; may have purulent vaginal discharge, pelvic pain and fever; dyspareunia Males: Painful urination; purulent yellow penile discharge; urethritis (decreased sperm count) Newborn: yellow discharge, both eyes

Diagnosis gram stain and culture of cervical secretions on Thayer Martin medium

Complications PID ectopic pregnancy infertility Chorioamnionitis ophthalmia neonatorum in newborns (associated with
severe eye infection and blindness)

preterm delivery sterility & pelvic inflammatory disease

Management (single dose only) Ceftriaxone (Rocephin) 125 mg IM (drug of choice for pregnant women) Ofloxacin (Floxin) 400 mg orally Treat concurrently with Doxycycline or Azithromycin for 50% infected w/ Chlamydia Ophthalmic ointment is routinely given as Credes prophylaxis to prevent opthalmia neonatorum (0.5% Erythromycin or 1% Tetracycline ointment for newborn babies)

Nursing interventions Health Teachings: Avoid sexual intercourse until cured of the infection or use condom to prevent transmitting the infection. Examination and treatment of sexual partner to prevent reinfection is necessary. Return to clinic for check-up in 4 to 7 days after completion of treatment. Monitor treatment

SYPHILIS
caused by motile anaerobic spirochete Treponema pallidum beautiful fast moving but delicate spiral thread can cross the placental barrier IP: 10 - 90 days can cause 100% fetal infection if primary and secondary infection is untreated, and 6-14% fetal infection in latent syphilis 2nd trimester infections cause spontaneous abortion, preterm labor, stillbirth and congenital anomalies 3rd trimester infection causes enlarged liver,spleen, skin rash and jaundice in a newborn

Signs and Symptoms

Primary Stage - painless chancre on genitalia, anus or mouth; most infectious stage

Secondary Stage - about 2 months after primary syphilis resolves; generalized maculopapular skin rash including palms and soles - painlesscondylomata lata on vulva - hepato/ splenomegaly - headache; anorexia; fever
Latent syphilis asymptomatic Tertiary Stage most destructive stage; neurosyphilis/permanent damage (insanity); gumma (necrotic granulomatous lesions), aortic aneurysm

Primary painless chancre

Secondary generalized rash

Tertiary - gumma

Diagnosis VDRL (venereal disease research laboratory test) or RPR (rapid plasmin reagin) nonspecific tests - for screening and to follow treatment course (decrease fourfold in 3-6 months) Fluorescent Treponemal Antibody AbsorptionTest (FTA-ABS) or Microhemagglutination Assay for Antibodies to TP (MHA-TP) specific tests for syphilis Dark-field microscopic examination of lesion- 1st and 2nd stage

Management Primary and secondary and early latent disease - Pen G (Benzathine Penicillin G 2.4 M U IM) - Alternatives: Tetracycline 500 mg orally QID or Doxycycline 100 mg orally BID Tertiary - IV Pen G Erythromycin & Cefriaxone are the drugs of choice for pregnant women Complications Congenital syphilis in newborn if untreated in late pregnancy Late abortion Stillbirth

Health Teachings : Educate women to recognize signs of syphilis. Educate women to seek immediate treatment if known exposure occurs. Encourage women to wear cotton underwear. Use condom during intercourse.

Sexual partners must also be treated to prevent reinfection. No sexual intercourse until lesions disappear After completion of treatment, the woman is treated monthly & the sexual partner at 3 months, 6 mos & 12 mos. Fetus will not be affected if the mother is treated before the 5th month. Emphasize the importance of screening for syphilis during the first prenatal visit for early detection & treatment. Inform patients treated with penicillin about Jarish Herxheimer reaction, a reaction to penicillin characterized by: fever, chills, malaise, headache, nausea, & tachycardia. This is a normal reaction that subsides within 24 hours.

HERPES GENITALIS
Sexually transmitted disease caused by the Herpes Simplex Virus 2 (HSV 2) Signs and Symptoms Flulike symptoms (malaise, myalgia, nausea, fever) Vulvar burning and pruritus Painful vesicles (cervix, vagina, perineum, glans penis) 2 - 20 days after exposure Painful genital ulcer Recurrent episodes 1-6x a year (during stress, fever, menstruation) Dyspareunia Diagnosis Viral culture Pap smear (shows cellular changes) Tzanck smear (scraping of ulcer for staining) multinucleated giant cells

Management Antiviral agents Acyclovir 200 mg PO q 4 hrs for 5 days Sitz bath Analgesics

Complications: Health teachings Meningitis NO sexual activity in the Neonatal infection (vaginal presence of lesions and 1014 days after lesions birth) subsided Trigeminal herpes zoster Keep vulva clean and dry in (facial muscle paralysis) the presence of lesions (wearing of cotton underwear) Sitz bath use foley catheter if retention persists Povidone- iodine douche and acyclovir NOT used during pregnancy

CONDYLOMA ACUMINATUM
Genital warts Genital or venereal warts caused by Human Papilloma Virus (HPV) May be a precursor to cervical cancer HPV types 6 & 11 condyloma acuminatum HPV types 16, 18 and 31 cervical cancer Signs and Symptoms: Single or multiple dry soft, fleshy painless (wartlike) growths on the vulva, vagina, cervix, urethra, or anal area; penis Can evolve into larger cauliflower-like growths Vaginal bleeding, discharge, odor and dyspareunia

Diagnosis Clinical Pap smear-shows cellular changes (koilocytosis) Acetic acid swabbing (will whiten lesion) Management Small lesions treated topically with podophyllin or trichloroacetic acid Larger lesions ablated with cryotherapy, laser vaporization or surgical excision. Recurrence rate : 20%

Complications Neoplasia Neonatal laryngeal papillomatosis (vaginal birth)

Health Teachings Inform the patient that infection with the virus increases the incidence of CERVICAL CANCER Therefore: Annual PAP smear is indicated

HUMAN IMMUNODEFICIENCY VIRUS (HIV and AIDS)

causative agent of acquired immunodefiency syndrome (AIDS) characterized by progressive immune system impairment destroys T cells and cell-mediated response makes the patient more susceptible to infections and unusual cancers

HIV and AIDS

Immunity declines and opportunistic microbes set in Retrovirus (HIV1 & HIV2) HIV is an RNA-based retrovirus that requires a human host to replicate Average time between HIV infection and development of AIDS: 8 -10 years HIV attacks and kills CD4+ cells (T helper cells) that regulate immune response No known cure

Mechanisms of Transmission Sexual intercourse Contact with contaminated blood, semen, breast milk and other body fluids Blood Transfusion IV drug use Transplacental / during birth Needlestick injuries

HIGH RISK GROUPs

Homosexual or bisexual Intravenous drug users BT recipients before 1985 Sexual contact with HIV+ Babies of mothers who are HIV+ THE INFECTED MOTHER CAN PASS THE VIRUS TO THE FETUS DURING PREGNANCY & CHILDBIRTH OR VIA THE BREAST MILK

Signs and Symptoms

1. Acute viral illness (1 month after initial exposure) : fever, malaise, lymphadenopathy

1.

3.

Clinical latency - 8 yrs w/ no symptoms; towards end, bacterial and skin infections and constitutional symptoms AIDS related complex; lymphadenopathy, night sweats, malaise, diarrhea, weight loss and unusual recurrent infections such as oral candidiasis, varicella zoster or herpes simplex CD4 counts 400-200
AIDS (full blown) - 2 yrs; CD4 T lymphocytes < 200 w/ (+) ELISA or Western Blot and opportunistic infections

Exhibits one or more of the ff

Extreme fatigue Intermittent fever Night sweats Chills Lymphadenopathy Enlarged spleen Anorexia Weight loss Severe diarrhea Apathy and depression PTB Kaposis sarcoma Pneumocystis carinii AIDS dementia

Opportunistic Infections
Candidiasis infection of esophagus, trachea, bronchi or lungs Cryptococcus meningitis Cytomegalovirus (CMV) retinitis >>> blindness Herpes simplex outbreaks lasting longer than 30 days HIV wasting syndrome Invasive cervical cancer Kaposis sarcoma in clients over age 60 Lymphoma Mycobacterium tuberculosis (TB) PCP (Pneumocystis carinii pneumonia) Toxoplasmic encephalitis Toxoplasmosis Varicella Zoster (Shingles)

HIV Infection

Effects on the Infant

Microencephaly CNS lymphomas CVAs Respiratory failure Lymphadenopathy Developmental anomalies

Transmission through the placenta (greatest near term) delivery due to exposure in birth canal secretions and blood(60%) breast milk

 Focus of care: treat the infection; reduce the risk of perinatal transmission through maintenance or reduction of viral load

Tx: oral Zidovudine initiated at 14-34 weeks AOG and continued throughout pregnancy, IV dose during labor and delivery and neonatal dose 8-12 hours after delivery
Suggested mode of delivery depends on viral load: >1000 copies/ml, C/S might reduce transmission Bathe the newborn as soon as possible after delivery; all needle procedures made after the bath

Laboratory Tests
ELISA Enzyme Linked Immunosorbent Assay (first test conducted) Western Blot confirmatory test

Rapid HIV test Suds hiv-1 Results are obtained in less than 10 minutes Color indicator similar to pregnancy test Positive result needs a confirmatory test

Laboratory Tests
Immunofluorescence assay (IFA): also confirmatory p24 antigen: detects HIV antigen in children <18 months; can be useful at any age; diagnostic if 2 or more (+) results Polymerase chain reaction Virus culture CD4+ : used to assess immune status, risk for disease progression, and the need for PCP prophylaxis after 1 year of age

 A (+) ELISA that fails to be confirmed by Western blot or IFA should not be considered (-) and repeat testing should take place in 3 - 6 months.

CD4+ T cell counts

monitors the progression of HIV As the disease progresses, usually the number of CD4 T cell counts decreases, with a resultant decrease in immunity. Normal CD4 T cell count: 500 1600 cells/L

HIV CLASSIFICATION
CATEGORY 1 CD4+
CD4 T cell count >500 cells/L: Immune system is healthy

500 OR MORE

CATEGORY 2 CD4+

200-499

CD4 T cell count between 200 499 cells/ L: Immune system problems

CATEGORY 3 CD4+

LESS THAN 200

CD4 T cell count <200 cells/L: Severe immune system problems

 CD4 count below 200: considered to have AIDS If a person has 2 or more opportunistic infections, she is considered to have AIDS, regardless of HIV testing or CD4 count.

CD4 to CD8 ratio

monitors the progression of the disease Normal ratio- 2:1 In HIV and AIDS, because of the low number of CD4, this ratio is low.

How to Diagnose
HIV+ 2 consecutive positive ELISA and 1 positive Western Blot Test AIDS+ HIV+ CD4+ count below 500/ml Exhibits one or more of the signs and symptoms stated above Full blown AIDS CD4 is less than 200/ml

Goals of therapy
slow the growth of the virus/ decrease the viral load prevent and treat opportunistic infections provide nutritional support and symptomatic treatment

PREVENTION A - ABSTINENCE B - BE FAITHFUL C - CONDOMS D - DONT USE DRUGS

DRUGS
NO cure NO vaccination Antiretrovirals are usually started when the CD4 count falls to 500 or below.

DRUGS
Prophylaxis with Co-trimoxazole (Bactrim) against Pneumocystis carinii pneumonia (PCP) when CD4 count falls below 200 cells/L. Prophylaxis with Rifabutin (Mycobutin) against MAC (Mycobacterium avium complex) when CD4 count falls below 100 cells/L.

Nursing Interventions
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Provide respiratory support. Administer respiratory treatment as prescribed. Administer oxygen as prescribed. Maintain fluid and electrolyte balance. Monitor for signs of infection. Prevent the spread of infection. Initiate standard and other precautions as necessary. Provide comfort as necessary. Provide meticulous skin care. Provide adequate nutritional support as prescribed.

Strict adherence to client confidentiality is important. Universal precautions, including personal protective gear, should be used consistently and correctly with every client every time there is a chance of coming into contact with blood or body fluids.

4 Components of Personal Protective Gear a. Gloves b. Gown c. Mask d. Face shield

Health teachings
For infected persons: 1. Avoid infections 2. Use latex condom to protect partner during sexual intercourse 3. Do not donate blood, sperm, organs or other body tissues 4. Do not share items with other persons that may be contaminated with blood & other body fluids 5. Do not breastfeed infant

For non-infected persons: 1. Stick to one partner, practice monogamous relationship 2. Use condoms 3. Avoid anal & oral sex 4. Practice good personal hygiene 5. Practice healthful living: exercise, adequate rest, nutritional diet, safe sex

6. Be aware of the signs & symptoms of infections: Weight loss of greater than 10% of body weight Chronic diarrhea, more than one month Prolonged fever, lasting more than one month AIDS cannot be transmitted by sharing foods, eating utensils, toilet, swimming pools, water

Precautionary measures for health workers: Handle all sharp instruments with care, use disposable needles & do not reuse as much as possible Protect yourself, increase resistance to infection by proper diet, exercise, rest & sleep Avoid body fluids label blood & other specimens of a person known or suspected with AIDS properly, clean blood spills with disinfectant Practice strict aseptic technique handwashing,wear gloves, clean, disinfect & sterilize Wear, protective clothing when necessary gloves, masks, goggles

ALWAYS KNOW YOUR DATE

ThAnK YoU Po!!!!

END